
Glass 
Book 



COPYRIGHT DEPOSIT 



DENT AL MEDICINE. 



AS CONNECTED WITH THE 



STUDY OF DENTAL SURGERY 






PRACTICAL TREATISE 



DENTAL MEDICINE, 



COMPENDIUM OP MEDICAL SCIENCE. 



AS CONNECTED WITH THE 



STUDY OF DENTAL SURGERY 



BY THOS. E. BOND, A. M., M. D. 

PROFESSOR OF SPECIAL PATHOLOGY AND THERAPEUTICS IN THE BALTIMORE COLLEGE OF 
DENTAL SCBGERY. 




PHILADELPHIA: 

LINDSAY & BLAKISTON. 

1851. 



/ 






Entered, according to the act of Congress, in the year one thousand eight hundred and 
fifty-one, by Lindsay 8c Blxkxston, in the Clerk's Office of the District Court of the Eastern 
District of Pennsylvania. 



PREFACE. 



The Baltimore College of Dental Surgery was or- 
ganized with the design of teaching Dentistry as a 
regular branch of Medicine, in which relation only, it 
can be regarded as a scientific pursuit and the practice 
of it esteemed a profession. 

With this view it was arranged that the Faculty 
should consist equally of Dentists and practicing Physi- 
cians, and to the author of this treatise was entrusted 
the chair of Special Pathology and Therapeutics. 
Commencing the performance of his duties with no 
larger amount of knowledge of the subject than is 
commonly possessed by medical men. he has been led 
to discover much more importance in it than at first he 
could have supposed to exist. Endeavoring to avoid 
the very natural error of exaggerating the value of 
isolated facts or doubtful statements, upon matters, at 
once novel and from the circumstances peculiarly in- 
teresting, he has found that many things which at first 
he was disposed to regard as unlikely, are, neverthe- 
less, well attested and established facts; and, after ma- 
ture investigation, he has become fully convinced that 
the relations of the teeth and their appendages with 
other, and even with vital, parts, are sufficiently impor- 
tant to be carefully studied both by the Dentist and 
Physician. 

After ten years experience as a teacher of these sub- 



jects, he has found it absolutely necessary that a com- 
pendium of medicine should be furnished, in which 
should be brought together, in a small compass, such 
selected information as should meet the wants of the 
Dental Surgeon, and as none has been prepared by 
another he has reluctantly undertaken the task. 

The difficulty of performing it will readily be con- 
ceived, when it is observed how much was proper and 
how much was irrelevant: how cautious it was neces- 
sary to be, that no needless matter should be intro- 
duced, and how careful that nothing pertinent should 
be omitted. 

Without the pretension of having done it well, the 
author is yet gratified that it has been done at all. 

Though particularly intended for the Dentist, the 
author flatters himself that he has presented the sub- 
ject in such a form as will render it deserving the at- 
tention of the general practitioner. 

It is not the custom of our profession to consider 
anything unworthy of attention which has any bearing, 
however remote, upon the benevolent pursuit to which 
we have devoted our lives, but to the most fastidious 
it may be said, that subjects which have been thought 
worthy the attention of Hunter and Rush, may be in- 
vestigated by all without fear of degradation. 

THE AUTHOR. 

Baltimore, Dec. 31, 1850. 



MY FATHER, 

THIS WORK IS RESPECTFULLY DEDICATED, 

B Y 

HIS SON 



CONTENTS 



PAGE. 

Introduction, . . . . . . . 13 

CHAPTER I. 
Preliminary Considerations, . . . .19 

CHAPTER II. 

Etiology, ....... 23 

The Atmosphere, ...... 25 

Heat and Cold, ...... 26 

Malaria, ....... 30 

Chemical Causes, ..... 31 

CHAPTER III. 

Symptoms of Disease, ..... 35 

Progress of Disease, ...... 36 

CH APTER IV. 

Diagnosis, ....... 39 

CHAPTER V. 

Treatment of Disease, ...... 47 

CHAPTER VI. 

Nature of Disease, . . . . . . 49 

Inflammation, ....... 51 

Consequences of Inflammation, .... 54 

Inflammation of the several parts composing the Mouth, and 

of the parts adjacent, ..... 64 

Inflammatory Fever, ..... 71 

Caries, ........ 81 

Mortification, or Gangrene, .... 82 



X CONTENTS. 

CHAPTER VII. 

PAGE. 

Ulcers, . . . . . . .89 

Local and Constitutional, . . . . . 91 

Simple Purulent Ulcer, . . . . .91 

Simple Vitiated Ulcer, ..... 92 

Callous Ulcer, . . . . .93 

Fungous Ulcer, ...... 94 

Sinuous Ulcer, ...... 95 

Carious Ulcer, ...... 96 

Cancerous Ulcer, . ..... 97 

Ulcers Dependent upon Constitutional Cause, . . 100 

Venereal or Syphilitic Ulcers, .... 100 

Scorbutic Ulcers, . . . . . 104 

Scrofulous Ulcer, ... . 106 

CHAPTER VIII. 

Tumors, . . . . . . . . 113 

Malignant — Osteo Sarcoma, . . . .113 

Fungous Hsematodes, Bleeding Fungus, Spongoid Inflam- 
mation, Soft Cancer, Medullary Sarcoma, . . 114 
Polypus, . . . . . 115 

Benign Tumors. . . . . . .116 

Sarcomatous or Fleshy Tumors, . . . 116 

Encysted Tumors, . . . . . .117 

Bony Tumors, . . . . . 118 

Exostosis of the Teeth, . . . . .120 

Tumors occasioned by Enlargement of Blood-Vessels, . 122 

1. Aneurismal Tumors, . . . . .122 

CHAPTER IX. 

Diseases of the Teeth and Face dependent upon Morbid 

Conditions, either general or of other parts, . 123 

Neuralgia, . . . . . . .123 

Neuralgia Faciei, or Facial Neuralgia, . . . 124 

Intermittent Neuralgia, . . . . .127 

CHAPTER X. 

Morbid Secretions of the Mouth, . . . 133 

CHAPTER XI. 

Morbid Effects of Conditions of the Teeth, and the parts 
immediately connected with them, upon the gen- 
eral system, ...... 149 



CONTENTS. XI 
CHAPTER XII. 

PAGE. 

Morbid Effects of First Dentition, . . . 151 

CHAPTER XIII. 

Sympathetic Diseases of Dentition, . . . 161 
Cholera Infantum, . . . . . .162 

Convulsions, ...... 164 

Cutaneous Eruptions, ..... 166 

Intertrigo, . . . . . . . 166 

Crusta Lactea or Milk Crust, . . . .167 

Strophulus, Tooth Rash, Red Gum, . . . .167 

Second Dentition, . . . . . . 168 

Third Dentition, ...... 169 

CHAPTER XIV. 

Effects of Diseased Teeth and Gums upon the General 

Health, . . . ... 170 

Phthisis Pulmonalis, induced by Dental Irritation, . . 190 

C.HA PTER XV. 

Wounds of the Mouth and Face, . . ._."'•. 209 

Fractures, ...... 224 

Fractures of the Jaws, ..... 226 

Dislocations, or Luxations, ..... 228 

Dislocations of the Lower Jaw, .... 229 

CHAPTER XVI. 

Particular Affections of the Mouth and adjacent parts, . 231 

Diseases of the Gums, ..... 231 

Epulis, 231 

Parulis 235 

Fistula of the Gum of the Lower Maxillary, having an Exte- 
rior Opening at the Hollow of the Chin, . . . 237 
Spongy or Fungoid Inflammation of the Gums, . . 238 
Hemorrhage from the Gums, ..... 240 

CHAPTER XVII. 

Diskases of the Lips, ...... 243 

Hare-Lip, 243 

Adhesion, ....... 247 

Contraction. ...... 247 



Xll CONTENTS. 

CHAPTER XVIII. 



PAGE. 



Diseases of the Glands and Gland-Ducts, . . . 253 

Salivary Tumors, ...... 253 

Tumors of the Submaxillary Gland, .... 256 

Notes of the Operation, ..... 260 

Tumors of the Parotid Glands, . . . .266 

Salivary Fistula, ...... 267 

CHAPTER XIX. 

Tumors requiring Amputation of a part or the whole of 

the Upper Jaw, ...... 271 

Amputation of the Lower Jaw, .... 273 

CHAPTER XX. 

Diseases of the Antrum, or Maxillary Sinus, . . 283 

Dropsy, or Retention of Mucus, .... 284 

Inflammation, ....... 289 

Suppuration, ...... 290 

Caries, Necrosis, and other Morbid Conditions of the Bony Walls, 291 

Softening of the Bony Walls, ..... 298 

Exostosis, ....... 298 

Fistula of the Superior Maxillary Bone, . . . 300 

Ozena, ....... 304 

Polypi and other Tumors, ..... 305 

Insects in the Cavity, ..... 310 

CHAPTER XXI. 
Diseases of the Palate, . . . . .313 



INTRODUCTION. 



The body of every animal is wisely contrived and perfectly 
fitted for the purposes it is intended to subserve. Every part, 
however minute, is necessary to the complete performance of 
the work of the whole; and a beautiful unity of purpose, and a 
necessary dependence of parts, are observable throughout the 
organization. 

So remarkable is this unity, and so certain this dependence, 
that a naturalist, by examining a fragment of any one of the 
bones of an animal, may determine the character of -the indivi- 
dual it represents. Having ascertained the size, figure, &c, of 
any bone, he may infer, with infallible certainty, that every other 
part of the body to which it belonged was formed in perfect 
proportion to this part, and with strict reference to the purposes 
for which this particular portion was designed. Should a natu- 
ralist ascertain that a single bone presented to him was con- 
structed for purposes of prey, he would immediately infer that 
a beast so provided must have had strong muscles and bones 
of the neck and jaws, to enable it to hold and tear the animals 
upon which it was intended to subsist ; hind legs of such a 
formation as to enable it to spring upon its prey ; claws to seize 
and hold it, and a digestive apparatus suited to the reception 
and assimilation of the food thus procured. 

Those who are familiar with the writings of Cuvier, will not 
need to be reminded of his beautiful reasoning upon this subject. 

The body of man must then be regarded as a unit, and 
though, for the convenience of description, we speak of its 
multitude of parts, it is a single organization, fed by one aliment, 
nourished by one blood, vitalized through one nervous system, 
directed to a common purpose, subject to one sovereign will, 
2 



14 INTRODUCTION. 

and pervaded by a general law of continuance, decay and dis- 
solution. 

As one part of the body is identified with all the others, it is 
necessary that a certain organic consent shall subsist between 
the several parts, in order that they may act in concert in car- 
rying on the business of life. For instance, the eyes must act 
together; the muscles of the trunk must aid the muscles of the 
limbs, and many more agreements of motion, infinitely compli- 
cated and astonishingly rapid, must subsist between different 
members of the body. 

The body has more to do than to perform certain acts by 
which it may be continued in being. It is, from its nature, 
liable, and from its condition exposed to injuries. It is con- 
tinually assailed by enemies from without and within. It has, 
therefore, certain signals of suffering, and is endowed with cer- 
tain aptitudes, through which any part more particularly attack- 
ed may receive succor from the rest. Moreover, the parts being 
connectedtogether by extension of common tissues, by blood- 
vessels and by nerves, the morbid conditions of one may readily 
be propagated to another. All this concert of parts, whether 
healthy or morbid, is called sympathy ;* though, in the case of 
healthy action, improperly so — and constitutes one of the most 
interesting and beautiful peculiarities of organized structures. 

In many instances the dependence of one part upon another 
is so direct, and the mode of communication so obvious, that 
there is no difficulty in detecting the process of sympathetic 
action or suffering that may be observed between them. In 
other cases, this concert of action depends upon undiscovered 
links of union, and is known to exist only upon the evidence 
of common observation. Besides this sympathy of parts, there 
is a general interest of the whole organism in the welfare of all 
its parts ; and severe or long continued suffering in any one, 
however comparatively unimportant, will commonly induce a 
general derangement of health, and may involve the whole body 
in serious and even fatal disorder. 

* Sw, with, rta9oi, suffering — fellow-suffering;. 



INTRODUCTION. 15 

Although in many cases no change in the structure of mor- 
bidly sympathizing parts might be discovered upon autopsic* 
observation, yet there is good reason to believe that sympathy 
is in fact a transfer or propagation of actual molecular change, 
and every physician knows that a disorder, primarily of little 
importance, may prove fatal by involving vital organs in a sym- 
pathy of disease. 

It cannot therefore be predicated of any organ, that its suf- 
fering is necessarily unimportant to the health of the whole 
system, since experience shows that the danger of almost all 
disorders depends very much upon the sympathies likely to be 
established in the course of their progress, and that the impor- 
tance of these sympathies is not always determined by that of 
the organ originally involved. 

The facts above stated are universally admitted by the medi- 
cal profession, and for the most part are recognized as impor- 
tant practical truths ; so much so, that the study of particular 
parts as isolated from the rest, with a view to treat certain local 
affections as independent phenomena, has long since fallen into 
disuse, and every physician and surgeon is expected to become 
conversant with all of medicine, as necessary to the proper care 
of any one of the organs of the body. An oculist, unless a 
thorough physician, would be utterly unqualified to treat dis- 
eases of the eye. The obstetrician must extend his knowledge 
far beyond the uterus, if he would claim any participation in 
the fellowship of science. 

Until very recently, however, the treatment of the diseases of 
the teeth seems to have been considered less a proper specialty 
of medicine, than a mere mechanical craft, requiring in the 
operator little more than manual dexterity and physical force. 
Surgeons and physicians were generally profoundly ignorant of 
the importance of these organs to general health, and were con- 
tented to leave them to the care of any who were willing to 
take charge of them. Even now diseases of the teeth are rarely 
mentioned in the medical schools, and eminent professors of 

' Avroi — w+, one's own eye — actual sight of the parts of a dissected body. 



16 INTRODUCTION. 

of surgery have publicly confessed themselves incompetent to 
teach their students how to extract them. 

In the course of time, however, men of inquiring minds and 
studious habits, finding themselves in the practice of a rude and 
imperfect art, the deficiencies of which were continually forced 
upon their observation, have been constrained to investigate 
the relations of the teeth to surrounding and distant parts. Well 
read medical men, waiving the general practice of the profes- 
sion, have turned their attention to dentistry, and of necessity 
have applied their previous information to the augmentation of 
dental pathology and therapeutics ; and, finally, the manage- 
ment of the teeth has come to be an acknowledged specialty of 
medical science, and is rapidly advancing in public and pro- 
fessional consideration. 

It is thus that other departments of the healing art have 
gradually won their way to their present position and impor- 
tance. Within a period comparatively recent, surgery in all its 
branches was regarded by physicians with sovereign contempt. 
Barbers were the operators, and mountebanks and old women 
dressed the sores. Midwifery was, if possible, held to be yet 
more despicable, and even within a few years, an eminent 
body of scientific physicians have declared obstetrics to be un- 
worthy the attention of a polite gentleman. 

It is unnecessary to say that surgery and obstetrics are now 
the leading branches of the profession, and are zealously prac- 
ticed by men of the first talents and greatest scientific and lite- 
rary acquirements. 

To our country belongs a large share of the honor of 
placing these two departments of medicine upon their proper 
level with other professional pursuits. 

The depressed condition of surgery and midwifery was the 
consequence of the vulgarity and ignorance of those who prac- 
ticed them, and the bad reputation thus acquired was a formida- 
ble obstacle in the way of those who attempted to elevate them to 
the dignity of scientific pursuits, but patient continuance in 
laborious and honorable effort has eventually succeeded in ac- 
complishing the desired result. 



INTRODUCTION. 17 

The practice of dental surgery was long degraded, from 
causes precisely similar to those evil influences which so long 
depressed kindred branches of the art. Disregarded by edu- 
cated men, it necessarily fell into the hands of the ignorant and 
rude, and precisely as surgery and midwifery have gradually 
emerged from their barbarous state and attendant disrepute, 
dentistry is now winning its way against all opposition, to its 
proper consideration. It is a matter of honest pride, that our 
country is again foremost in this laudable work. 

The purpose of the present work is to treat of dental surgery 
as a distinct and proper specialty of medicine, and to present 
to the reader a digest of information, prepared with particular 
reference to the morbid connexions certainly existing between 
the teeth and the rest of the body. 

These connections are far more important than is generally 
supposed by physicians or dentists ; and the reader of the fol- 
lowing pages will probably be surprised to find so great a variety 
of disorders treated of as directly or indirectly concerned in the 
production of pathological conditions observed in the mouth ; 
and his surprise will perhaps be greater to find so many and 
so serious diseases of other organs traced to their primary seat 
in morbid conditions of the teeth. Yet the object of the author 
has been to condense this treatise as much as consistency would 
permit, and to admit nothing foreign to the subject properly 
under consideration. 



TREATISE ON DENTAL MEDICINE. 



CHAPTER I 



PRELIMINARY CONSIDERATIONS. 



The human body is liable to changes which more or less 
disturb the regular and healthful performance of the many 
functions* necessary to the completeness of its life, or in 
other words, to disease. These changes are commonly at- 
tended with alterations of the phenomena which experience 
authorizes us to regard as natural or normal, or in other 
words, by symptoms^ which indicate the character and seat 
of the change which produces them. 

When parts thus diseased are inspected, we generally per- 
ceive alterations in their usual appearance and structure. Not 
unfrequently, however, the changes are too obscure to be de- 
tected by our present means of investigation. 

Many attempts have been made to define the essential nature 
of disease, but all have necessarily failed. It is impossible to 
frame with philosophical accuracy a definition of disturbed or 
altered conditions, unless we perfectly understand the nature 
of the organs, and the mode of their acts. We cannot under- 
stand the ultimate cause of morbid phenomena, while ignorant 
of the essential nature of life itself, as manifested in the healthy 
performance of function. 

* By function is meant the particular part which each organ performs 
in the mechanism of life. The liver is an organ, its function is to secrete 
bile. 

t Symptoms are those observable differences from the healthy perform- 
ance of function which lead us to suspect and often to detect disease. 



20 PRELIMINARY CONSIDERATIONS. 

It is important to the student to know that medical language 
does not pretend to the precision of abstract philosophical 
science. Medical definitions are not to be regarded as accu- 
rately stating the nature of things, but simply as descriptions 
which may serve for practical purposes. This fact has been 
forgotten by many eminent medical writers, and their efforts 
to be absolutely accurate have often led to serious mistakes, 
and always to confusion of ideas and contradiction of facts. 
The study of essences belongs to metaphysics, not to practical 
science, and having failed to reach any truth by a analyzing 
mind, it will hardly prove successful in its attempts upon the 
body. 

We wish it then to be clearly understood, that medical 
terms are to be received in a conventional sense, and that, 
while they serve perfectly well to convey what knowledge we 
have of curative science, they will not bear the test of strict 
philosophical examination. For example, the word life> as 
used by medical writers, does not mean the essential vital 
principle, but the aggregate of the functions of the body : not 
the ultimate cause which sets the machinery in motion, but 
its effect in the production of organic acts. Disease means all 
the morbid phenomena observed in a case, together with the 
structural changes upon which these phenomena depend, and 
any other more remote injury which may be concerned in their 
production. Thus a patient may complain of nausea ; this 
sickness may be consequent upon defective digestion ; the de- 
fective digestion upon interruption of the function of the liver; 
the interruption of the hepatic* function upon change of 
structure in that organ ; and that change of structure upon 
more minute pathologicalf conditions. Strictly speaking, we 
might regard all this train of evils as symptoms merely of 
some obscure and inappreciable change which constitutes 
the disease. But in that case the word would be of 
no practical use. These instances may suffice to illus- 
trate our meaning, and the student may be saved much 

* Hepar — the liver. 

t Pathological— xo0o$, suffering, xoyof, discourse ; that which relates to 
diseased conditions. 



PRELIMINARY CONSIDERATIONS. 21 

embarrassment by keeping the fact thus presented always in his 
mind. Many false theories and much bad practice have resulted 
from attempts to philosophise in medicine. It is an experi- 
mental science, embodying the results of long experience and 
protracted investigation. As such it is true, and worthy of all 
confidence. It is impossible to tell why any medicine produces 
its effect — we do not understand the philosophy of it ; but we 
know what effect it does produce, and that knowledge is suffi- 
cient, and infinitely more important. 

I will not trouble my readers with a recapitulation of the many 
definitions of disease proposed by eminent writers, let it suffice 
to say, that all of them are improper, and many of them strangely 
absurd. We can describe disease readily enough, but we cannot 
detect and exhibit its primary elements. Probably we would 
not be practically wiser if we could do so. 

Life, then, may be considered as the effects produced by or- 
ganization. Health, the regular and orderly development of 
these effects. Disease, disorder and irregularity in their mani- 
festation, or impediment to the accomplishment of one or more 
of them.* 

Physiology! has to do with the performance of healthy or 
natural acts, and physiological medicine or hygiene with the 
preservation of health. Pathology is the science of diseased 
conditions. Therapeutics^ the art of applying remedies for the 
cure or relief of disease. Anatomy§ is the study of the body 
as an organized machine. Surgery,]| manual or mechanical 
medicine. Etiology, *$ the science of morbific causes. 

In the present treatise, it is our purpose to examine the 
etiology, pathology and treatment of morbid conditions, with a 
special reference to practical dentistry. 

* Roche and Sanson, Nouveaux Elements. § Avatsfxvco, I cut up. 

t Sikhs, nature, Xoyos, discourse. || X«p, the hand, tpyov, work. 

t©£part£vw ; I cure. IT Etfu-s, cause. 



ETIOLOGY. 23 

CHAPTER II. 

ETIOLOGY. 

Causes of disease may be external or internal. By external 
causes we mean all those agents which are independent of our 
own organization, whether they produce their impression upon 
the outward or interior parts of the body. Thus poison inhaled 
or swallowed, would be an external cause though acting upon 
internal surfaces. 

By internal causes we mean all such as are produced from 
our own organization ; as by the action of one part of the body 
upon another ; or by the connection and dependence of parts ; 
or by the influence of the intelligence itself, which often em- 
barrasses and sometimes overwhelms the physical machine. 

By general causes, we mean such as affect simultaneously a 
large part of the corporeal system. By local, those which are 
very much circumscribed in their sphere of action. These 
terms, like most others used in descriptive science, are not 
philosophically precise, since every cause must be supposed to 
act upon some structures to the exemption of others ; but they 
are sufficiently accurate to convey the meaning intended. It 
must not be supposed that general causes necessarily produce 
general diseases, and vice versa. A local cause, acting only 
upon a very small surface, may produce universal disorder, 
while a general cause may beget a strictly local disease. A 
plunge into cold water, drenching the whole surface, may pro- 
duce nothing more serious than a tooth-ache ; while a prick of 
a finger may cause serious general disorder and even death. 

Further subdivisions of causes are based upon the character 
of the effects which they produce. Some stimulate or increase 
the action of the blood-vessels; others debilitate or lessen such 
action. Some act mechanically, dividing, tearing, bruising, &c; 
others chemically, burning, corroding or decomposing. 

Predisposing causes are those which exert an influence suffi- 
cient to make parts more liable to disorder, without actually 
disordering them. This term, again, is not absolutely accurate, 



24 ETIOLOGY. 

for we cannot conceive of these causes acting in any other way 
than in the production of disease, which doubtless they do, but 
in so feeble a degree as to give out no symptom of its existence. 
Exciting or efficient causes are those which immediately precede 
disorder, and are reasonably inferred to have induced it. It 
must not be supposed, however, that these divisions are abso- 
lutely descriptive of certain agents which permanently belong to 
either of them. A cause which predisposes in one instance 
may excite in another, and vice versa. For example, a man 
may be exposed to intense cold, and while extremely chilled he 
may drink a large quantity of ardent spirits, and fever may en- 
sue. In this instance the cold would be regarded as predis- 
posing and the alcohol exciting. On the other hand, a man 
may become intoxicated, and while thus enfeebled he may be 
exposed to cold and fever or inflammation might result. In 
this case, the alcohol and its effects would be the predisposing, 
the cold the exciting, cause. 

Some causes are utterly unknown, but are inferred to exist 
as agents differing essentially from known causes, from the pe- 
culiarity and uniformity of their effects. These are called spe- 
cific. The causes of scarlet fever and of whooping cough are 
examples. 

Almost every thing without and within us may be in some 
way or other productive of disorder to the human body. The 
air we breathe may carr,y into the inmost recesses of our system 
invisible poisons, to hurt the lungs or spoil the blood ; it may 
withdraw our heat too rapidly, or it may fail to relieve us of 
our excess of caloric ; it may itself undergo chemical changes 
which deteriorate its qualities and render it more or less unfit 
for respiration. The food we eat may pain or sicken or con- 
vulse us. It may suddenly prostrate, or gradually destroy us. 
Water, even when pure, may irritate the disordered organs of 
digestion, and when impure may carry unsuspected drugs into 
the stomach. Even the light of heaven may harm the delicate 
eye, and the sun's own heat exhaust the strength or inflame the 
brain ; while that all-pervading and powerful agent which we 
call electricity, entering our bodies at will, and playing upon 



ETIOLOGY. 25 

our nerves at pleasure, may work in us fearful but inscrutable 
changes. 

We are constantly exposed to the rude contact of bodies 
harder than our own, by which our tissues may be divided, 
broken, torn or penetrated ; while other substances possess a 
mysterious power, to combine chemically with the elements 
which compose our bodies, and form of them new products, thus 
altering and disorganizing the parts subjected to their action. 

Nor are the enemies of health and life within us less active 
or efficient. The exquisitely organized body is continually un- 
dergoing change, and in them all, is at work an irresistible law, 
which impels the whole to decay and dissolution. Linked 
together by exquisite sympathies, traversed by numberless 
nerves and blood-vessels, performing most delicate and impor- 
tant functions, and pervaded by a powerful moral intelligence, 
whose passions and appetites excite and depress the physical 
system to its utmost limits of endurance, the parts of the body 
are continually liable to become diseased, and to radiate disor- 
der throughout the whole. 

It will be impossible for me to introduce into the present work 
a full examination of each of the many causes of disease which 
might be worthy of particular notice. I will only ask the 
attention of the reader to the consideration of such as are most 
important to us, as being concerned in the production of those 
diseases which the dental surgeon is expected to treat. 

The Atmosphere* 

The air acts upon us in a variety of ways. By its pressure 
upon us it keeps in form ; without that pressure the fluids 
coursing within us would overcome the resistance offered by the 
coats of their vessels, and universal turgescence, interruption of 
function, and death would ensue. 

It furnishes us with the oxygen necessary to preserve the 
vitality of the blood. Were the natural proportion of this 

» The atmosphere is composed of two great elements, called oxygen and 
nitrogen, with a small portion of carbonic acid. 
3 



26 ETIOLOGY. 

element increased or diminished, we must suffer hurt. It is 
also the vehicle by which watery vapor acts upon our outward 
and inner surface, and the medium by which caloric or the 
matter of heat is brought into contact with us. It is therefore the 
means by which we feel those hygrometrical changes which 
have so much to do with our health, and the vicissitudes of 
temperature which, as morbific causes, are hardly less important. 

Increase in the density of the air has been known to produce 
serious epidemic affections. Persons who ascend high moun- 
tains generally suffer much from embarrassed respiration, and 
hemorrhages and pulmonary affections have been traced to 
changes in the mechanical action of the atmosphere. 

Unless the supply of air be unequal to the want, the quantity 
of oxygen in the atmosphere has never been found deficient ; 
but where persons have resided or been confined in crowded 
and ill-ventilated rooms, the most serious consequences have 
often resulted. When the deficiency of air is not so great as 
to produce rapid and violent results, the health often languishes, 
the complexion fades, the strength fails, and diseases of various 
kinds make life wretched, and shorten its duration. In the 
gorges of mountains are often found decrepid, deformed, and 
even idiotic people, who bear sad testimony to the evil effects 
of depraved air. 

Heat and cold are universally recognized as having much to 
do with the causation of disease. Caloric or the matter of heat 
pervades all bodies, and constantly tends to an equilibrium. 
The animal heat which is elaborated by some obscure process, 
but little understood, obeys the common law of caloric, and 
constantly passes off to bodies less warm, or receives increase 
from those more heated. Our sensations of heat and cold are 
therefore nothing more than indications of the loss and supply 
of caloric to our surface. When it passes off in greater quan- 
tity than we can supply it with comfort to ourselves, we com- 
plain of cold; when surrounding bodies draw less from us than 
we are in the habit of supplying, or communicate to us of their 
own excess beyond our wants, we feel heated. These variations 
in our state of calorification are not limited in their effect to the 



ETIOLOGY. 27 

production of certain sensations. They are capable of causing 
great disorder in the performance of function, and creating 
morbid conditions of the most serious kind. Heat is an ex- 
citant, cold must therefore be a depressing agent. Heat induces 
increased action of the heart and arteries ; cold diminishes that 
action. But in considering the consequences of agents acting 
upon the human body, we must always remember that it is a 
living machine, and is not merely passive under modeling influ- 
ences. A thorn penetrating the substance of an inanimate ma- 
chine, would produce no other consequence than the mere 
perforation ; but should it pierce the human body, it would 
induce a succession of phenomena, depending upon the vitality 
of the parts injured. Heat acting upon a bar of iron will expand 
it; cold will contract it: acting upon the human body, heat 
will not only expand its tissues, it will excite the parts to in- 
creased action. Cold will not only contract the tissues, but 
lessen action. Further, heat, if long continued, will exhaust 
the vigor of the nervous and vascular system, and thus debili- 
tate the whole frame ; for it causes the organs to work more 
rapidly than usual — consequently to consume more of the means 
of action, while it adds nothing to those means. It does not 
increase the amount of blood, nor enrich its quality, but it causes 
it to be more rapidly circulated and consumed; it provides no ad- 
ditional nervous energy, but causes greater expenditure of it. In 
the course of such unusual consumption and expenditure, the 
parts appear more than commonly vigorous, but the result must 
be that the supply of means soon falls below the usual con- 
sumption, and languor, depression or exhaustion result. Heat,* 
in other words is an excitant or stimulant, and all agents of this 
class will enfeeble as a secondary and ultimate effect. 

Cold, being the opposite of heat, is of course depressing, as 
being the withdrawal of an excitant. But there is in the living 

* It will be perceived that we use this word in the popular sense, as 
conveying the idea of a certain sensation. When we speak of heat as an 
external agent, we of course mean the presence of caloric in a quantity so 
unusual as to create the sensation of heat. Caloric itself is absolutely 
necessary to life, and does not exhaust vitality when present in its normal 
or natural quantity. 



28 



ETIOLOGY. 



body a recuperative power, which exerts itself powerfully to 
overcome morbid influences. This power we call reaction, and 
its chief phenomenon is increase of vascular action, up to and 
beyond the natural standard. When cold is suddenly applied 
to the body, the first effect is to lessen vascular action and ner- 
vous sensibility ; but unless the application be very long con- 
tinued, the circulation will soon resume its vigor, a glow of 
warmth will succeed to the chill, andperhaps the heart and 
arteries may work with a force and frequency incompatible with 
health. 

In order to explain certain pathological conditions, of very 
common occurrence in every part of the body, it is also im- 
portant to observe that when parts are suddenly chilled by the 
rapid abstraction of their natural heat, their nervous excitability, 
or the power of being impressed by agents, is increased.* 
Every one has remarked the extreme sensibility of the fingers 
on a cold day, and dentists are well aware that delicate patients 
cannot endure protracted and painful operations in the winter as 
patiently as in summer. 

To a man nearly frozen, it would be death to bring him to a 
blazing fire. Frost bites are nothing more than burns inflicted 
at very low temperatures, upon parts unusually susceptible 
through the abstraction of heat. 

If this be true of cold, the converse is true of heat. Pro- 
tracted heat, as indeed the long action of all stimulants, wears 
out the excitability, and renders the body difficult to be im- 
pressed. Debility or weakness may be connected with both of 
these nervous conditions; hence weakness alone is not a char- 
acteristic of any disease, it is merely a circumstance of it. A 
man half-starved would be very weak, and might be too much 
excited by a single glass of fermented liquor : another, exhausted 
by long continued intemperate drinking, might be equally 

* This is true in the case of the sudden diminution of any of the essen 
tial means of life. If food be withdrawn for a considerable time, the accu- 
mulated excitability of the system will make it dangerous to give the 
starving man an ordinary meal. If blood be abstracted, the whole system 
becomes more easy to be acted upon by food, medicines, &.c. 



ETIOLOGY. 29 

debilitated, but could not be excited by immense quantities of 
distilled spirit. 

These remarks upon the effects of cold and heat will enable 
us to understand the mode of production of many particular 
affections, through the agency of atmospheric changes. 

Excessive moisture in the air is also a common cause of 
disease, but only because the watery vapor withdraws our heat 
much more rapidly than dry air, at the same temperature, 
would do. 

Air is also the vehicle through which aerial poisons of various 
kinds are brought to act upon us. 

We have mentioned specific causes, as the unknown agents 
which produce peculiar and uniform disorders. Some of these 
causes can only produce their effects through the air when it is 
highly charged with the poison ; others can act at great dis- 
tances from their source, and apparently when much diluted by 
atmospheric mixture; and others have never been traced to 
any local origin, and while apparently poisoning the air over 
immense spaces, produce no change in it which is appreciable 
to our nicest tests. 

Of the first class are the contagious, which may be propagated 
either by direct contact or by atmospheric infection within short 
distances: of the second are the causes of endemic diseases, 
and of the third are the inscrutable agents which produce those 
wide spread disorders which we call epidemics* 

The scope of our work does not include the causes of con- 
tagions and epidemics ; but as certain endemic diseases fre- 
quently exhibit themselves in the mouth and face, and very 
much embarrass the dentist who may unfortunately be ignorant 
of their cause, nature and treatment, it is necessary for us to 
notice particularly the atmospheric vitiation, which causes 
them. 

•Endemic, tvS^oj; epidemic, (rttS^oj. By endemics we mean dis- 
eases largely prevalent in a certain vicinity, and often traceable to a local 
cause, and always dependent upon such. An epidemic has no connection 
wiih locality, and evidently does not spring from a local cause. The 
yellow fever is au example of an endemic ; cholera of an epidemic. 
3* 



30 ETIOLOGY. 

It has been observed, from time immemorial, that the borders 
of sluggish streams and stagnant pools, and the vicinity of 
marshy grounds are unwholesome, and that persons -who dwell 
in such places, or even remain there during a short time 
of certain seasons, are subject to peculiar disorders, not ob- 
served elsewhere, and evidently not produced from ordinary 
influences. To the causes of these diseases, which, though 
unknown in their nature, must be immediately connected with 
the peculiarities of the locations in which only they act, several 
names have been given, such as marsh miasma, malaria and 
marsh poison. 

To this agent must be attributed by very far the greatest part 
of endemic diseases, and those which are most destructive of 
health and fatal to life. The yellow fever of the West Indies 
and America, the plague of the Mediterranean coasts, the coast 
fever of Africa, the jungle fever of India, the remittent or bilious, 
and the intermittent or ague, of many places, and many other 
affections which it is unnecessary to mention, are the produc- 
tions of the poisonous emanations from wet soils. 

We have not as yet been able to discover the nature of marsh 
poison. The most careful analysis of air selected from the 
pestiferous fens has not developed any alteration in the pro- 
portion of the elements of the atmosphere nor any foreign 
matter whatever. Yet we have sufficient evidence to justify 
us in believing that the poison does act through the atmos- 
phere, and the failure to detect only proves the inadequacy of 
our means of analysis. 

Malaria is evolved during the day by the action of the sun 
upon wet ground containing dead vegetable matter. It as- 
cends with the watery vapor which is simultaneously disen- 
gaged, and commonly requires to be precipitated and concen- 
trated by the cold of evening before it exerts its malign influ- 
ence. Hence the popular dogma that summer dews are un- 
wholesome; an opinion based upon the experience of the fact 
just stated. The danger, however, is not from the dew, but 
from the concentrated malaria simultaneously present. 



ETIOLOGY. 31 

There are cogent reasons for supposing that the cause of the 
endemics in question is not one and the same for each of the 
distinct disorders belonging to the category of malarious dis- 
eases, but that each has its separate and peculiar poison, though 
all are the product of vegetable decomposition under the com- 
bined operation of heat and moisture. It would be incompat- 
ible with the design of the present work to discuss this and 
other interesting questions connected with these wide-spread 
and destructive emanations. The subject, however, is well 
worthy of the careful attention of every man, and especially of 
every student of medical science. Ignorance of facts con- 
nected with this subject which might be learned in a few hours, 
annually causes the death of many, who unnecessarily expose 
themselves to the assaults of fatal pestilence. 

The only known prophylactics* against malaria are the in- 
tervention of thick woods between the source of the poison and 
the house, and the rarification of the evening air of the dwell- 
ing by fires. 

It is not necessary to particularise the mechanical and chem- 
ical causes which may injure the human body generally, nor 
would it be consistent with our purpose to examine in detail 
the effects of aliments, occupation, &c, in the occasional pro- 
duction of disease. These considerations belong to general 
hygiene, and if introduced here, would swell our work to an 
inconvenient size. We shall, therefore, only allude to those 
matters as we may have occasion in the progress of our dis- 
cussions. 

In organs endowed with a high degree of vitality, the laws 
of chemical affinity are inoperative, being subordinate to an in- 
explicable and all-controlling law of life. This, however, is 
only true within certain limits, for some chemical agents will 
always enter into combination with the animal tissues, whether 
living or dead, when brought into contact with them. 

The enamel and even the bony structure of the teeth are 
acted upon very readily by many acids, both vegetable and 
mineral, which combine with the earthy base, lime, and form 
* ripo<}>w\aSis, — prophylaxis, from rtpofv\a,Gou — I guard against. 



32 ETIOLOGY. 

new compounds with it, breaking up of course, the integrity of 
the organ. The enamel is a crystalline mineral substance and 
possesses no vital organization, consequently it is quite as lia- 
ble to be acted upon by chemical agents while in its normal 
place, as it would be when separated from the body. It is 
therefore very easy to perceive, that this external defence of 
the tooth may be very easily penetrated and the ivory of the 
organ laid open to the action of alimentary matters and fluids of 
the mouth. 

It is from this cause that what is called caries results. Unfor- 
tunately the word is used to express an affection of the 
bones entirely different from the peculiar disorganization called 
caries of the teeth. The former is a modified vital process, 
analogous to ulceration of the soft parts, the latter is a chemi- 
cal erosion. Dr. Westcott has published* the results of some 
interesting experiments made by him for the purpose of test- 
ing the activity of certain chemical agents upon the teeth. 
The mode of these experiments was as follows : 

A water bath was prepared, kept constantly at 98° by a 
spirit lamp, and regulated by a thermometer. In these were 
placed vials containing the substances to be tested. In each 
of these was placed a human tooth — care being taken to select 
those of as similar organization as possible, and whose enamel 
was perfect. 

A hundred articles, such as are most commonly used as food, 
condiments or medicine, were thus tested, and uncommon care 
was taken to watch the progress of the chemical action upon 
the teeth, subjected to such application. 

The results of these experiments are summed up by Dr. 
Westcott in the following propositions : 

1st. Both vegetable and mineral acids act readily upon the 
bone and enamel of the teeth. 

2d. Alkalies do not act upon the enamel of the teeth. The 
caustic potash will readily destroy the bone by uniting with its 
animal matter. 

* Vide Amer. Journal of Dental Science, Sept. 1843. 



ETIOLOGY. 33 

3d. Salts, whose acids have a stronger affinity for the lime 
of the tooth, than for the base with which they are combined, 
are decomposed, the acids acting upon the teeth. 

4th. Vegetable substances have no effect upon the teeth 
until after fermentation takes place, but all of them capable of 
acetic fermentation, act readily after this acid is formed. 

5th. Animal substances, even while in a state of putrefac- 
tion, act very tardily, if at all, upon either bone or enamel. On 
examining the teeth, subjected to such influence, the twentieth 
day after the experiment, no visible phenomena were presented 
except a slight deposit upon the surface of a greenish slimy 
matter, somewhat resembling the green tartar often found upon 
teeth in the mouth. « 

Acetic and citric acid so corroded the enamel in forty-eight 
hours that much of it was easily removed with the finger nail. 

Acetic acid or common vinegar, is not only in common use 
as a condiment, but is formed in the mouth whenever substan- 
ces liable to fermentation are suffered to remain about the teeth 
for any considerable length of time. 

Citric acid, or lemon juice, though less frequently brought 
into contact with the teeth, acts upon them yet more readily. 

Malic acid, or the acid of apples, in its concentrated state, 
also acts promptly upon the teeth. 

Muriatic, sulphuric, and nitric acids, though largely diluted, 
soon decompose thejteeth. These are in common use as tonics.* 

Sulphuric and nitric ethers have a similar deleterious effect ; 
these are used frequently as diffusible stimulants. The acids of 
some of the salts also corrode the teeth. Super tartrate of 
potash, or cream of tartar, destroys the enamel very readily. 
This article is frequently used to form an acidulated beverage. 
(It is also the basis of certain popular dentifrices, which 
whiten the teeth by corroding their surfaces.) Raisins so cor- 
roded the enamel in twenty-four hours that its surface present- 
ed the appearance and consistency of chalk. 

Sugar had no effect until it had undergone acetous fermen- 
tation. 

* Tonics are medicines which invigorate the system, or impart tone to 
the muscular fibres. 



CHAPTER III. 



SYMPTOMS OF DISEASE. 



All changes of normal phenomena observed to attend dis- 
eases are called symptoms. Sometimes we know nothing more 
of the disease than that it causes certain appearances, and in fact 
we are commonly compelled to regard the symptoms as the evils 
to be combatted, and to rely mainly upon experience for the 
proper means of relief. The skill of the physician and surgeon 
is chiefly exercised in interpreting these signs correctly and pur- 
suing their indications to the desirable result. 

Sometimes a case will present but a single symptom, as pain 
in a tooth; at other times, while one particular symptom in- 
dicates the seat and nature of the primary malady, a number 
of secondary and collateral signs will claim attention and 
clamor for relief, and again all the morbid appearances may be 
so general and vague as to afford no satisfaction as to the na- 
ture and seat of the disease. 

Local symptoms are those which present themselves in the 
very seat of the disease ; sympathetic, such as are manifested in 
other organs than that primarily affected, and which are depend- 
ent upon the distant disease, being due to their relations with 
it through the brain, spinal marrow and sympathetic nerves. 
General symptoms are such as affect a large part of the body 
simultaneously. 

Generally speaking the local symptoms are the most import- 
ant as they indicate the seat of the disease upon the extent and 
intensity of which the suffering of the sympathizing organs de- 
pends. It is always exceedingly important to detect these lo- 
cal symptoms and deduce from them correct knowledge of the 
pathological condition they represent. But this is often a mat- 
ter of great difficulty, as the greater intensity and obtrusiveness 



36 SYMPTOMS OF DISEASE. 

of sympathetic symptoms may deceive us and we may readily 
mistake them for local symptoms. 

Sympathetic symptoms are worthy of careful attention, for 
though caused by distant disorders, yet they manifest real dis- 
turbance in the organs to which they belong. And it often 
happens that these sympathizing organs suddenly assume dis- 
eased conditions of the most alarming character. The judi- 
cious physician will watch them carefully, especially if the 
brain be the seat of them. 

General symptoms are those manifested by the heart and ar- 
teries, and the nervous system, which, acting throughout the 
whole system when disordered, give out everywhere signs of 
distress. 

Progress of Disease. 

A disease is said to be continuous when its prominent symp- 
toms are not interrupted by any law of the disorder, from the 
commencement to the end of it. We have an instance of this 
in continued fever. 

We use the term intermittent to distinguish a very important 
class of disorders, characterized by regular periodical disap- 
pearance and return of symptoms. Such are agues. 

Remittents are those diseases which present, as a character- 
istic symptom, a periodical abatement of intensity, very mani- 
fest, though not amounting to intermission. The bilious fever 
of our country belong to this class. 

Diseases are said to be acute when they run their course rap- 
idly: Chronic* when they occupy a comparatively long time 
in their progress. 

The student must not suppose that the term acute, necessa- 
rily implies violence or intensity. It is true that violent dis- 
orders are commonly of brief continuance, but it does not fol- 
low that all diseases of brief continuance must be severe. 
Neither is it true that chronic diseases are less serious than 
those which are more rapid, for the reverse is very frequently 
the case. The terms acute and chronic have reference to dura- 
tion and not to intensity. 

*XpoK>s — time. 



SYMPTOMS OF DISEASE. 37 

As a general rule, all diseases abate their severity early in 
the morning and increase it in the evening. This increase is 
called an exacerbation ; if very severe, a paroxysm. This last 
term has a peculiar meaning when applied to intermittents. 

The phenomenon of intermission is one of the most curious 
and inexplicable of all observed by the physician. The dis- 
eases characterized by this peculiarity consist of an indefinite 
number of attacks or paroxysms, each of which, after having 
exhibited a succession of conditions, disappears, leaving no 
symptom of disease, except the exhaustion of the patient be 
considered such. After a certain time of intermission or ex- 
emption, another attack is sustained, and so the disease pro- 
gresses, by alternate paroxyms and departures. Each parox- 
ysm consists of a chill or cold stage, a fever or hot stage, and a 
sweating stage in which the fever disappears, and the intermis- 
sion commences. 

If there be a paroxysm in every twenty-four hours, the dis- 
ease is called a quotidian ;* if it occur on alternate days, a ter- 
tian,! if there be two days of intermission, a quartan,! &c. 

Sometimes there will be two paroxysms a day, a double 
quotidian ; sometimes two paroxysms on alternate days, dou- 
ble tertian ; or, the double tertian may consist in the daily oc- 
currence of a paroxysm, at hours coinciding, or the alternate 
days. Many other modifications of periodicity occur in 
the disease, but the intermission is distinct in all. The quo- 
tidian and tertian are by far the most common forms of ague. 

It not unfrequently happens that the paroxysms occur regu- 
larly, but do not prevent the ordinary succession of chill, fever 
and sweat, but merely cause excessive pain in some sensitive 
part, usually occupying but little space. This pain obeys the law 
of intermission and periodicity as other forms of paroxysms do, 
and is known as intermittent neuralgia. || It is very import- 
ant that the dentist should be well acquainted with this form of 
disease, as it frequently occurs in the teeth and parts about the 

• Quotidian — quotidies, daily. f Tertian — tertius, three. 
X Quartan — quartus, fourth. 

|| Neuralgia, from ytvpov, neuros, a nerve, and cayoj, algos, pain. 
4 



38 SYMPTOMS OF DISEASE. 

jaws, &c, and maybe easily confounded with tooth-ache from 
local causes ; a mistake which has caused the infliction of 
much unnecessary pain and the loss of valuable teeth. 

Remittent diseases are characterized by a remarkable diurnal 
abatement of their symptoms, not amounting to intermission, 
but apparently analagous to it. Some of the most fatal dis- 
eases which afflict the human family are of that class. For ex- 
ample, yellow and bilious fever. 

Certain diseases always present the same symptoms, and in 
the same order, and perseveringly run through them all un- 
checked by treatment, or the circumstances of age, sex, con- 
stitution, &c, which powerfully control other diseases. The 
small pox, measles, hooping-cough, &c, are examples of this 
class. They arise frrm specific causes, and are sometimes 
called specific diseases, though this term includes other dis- 
eases of entirely different character. 



CHAPTER IV 



DIAGNOSIS. 



Diagnosis* The art of following symptoms to their proper 
pathological cause and ascertaining the character, location 
and extent of disease, of which they are the signs. This, 
of course, involves the discrimination of one kind of disorder 
from all others, and is often extremely difficult, sometimes im- 
possible. When one or more local symptoms are prominent 
beyond others, we may sometimes ascertain at once the seat of 
the disease, but even in such cases we must not decide until 
we shall have ascertained whether these local symptoms are 
primary or sympathetic ; an inquiry which often requires much 
general knowledge of disease, and a capacity for close consec- 
utive reasoning. 

When our attention is first called to a patient, we often en- 
counter a large number of symptoms of different kinds, proceed- 
ing from various organs and all calling for relief. In the midst 
of this general out-cry of organs, the attentive observer will 
generally detect one voice of distress more earnest than the 
rest, and directing his inquiry to the part thus designated, he 
frequently comes at once upon the cause of the general trou- 
ble. The local signs are always the most important, and withal, 
often the most obscure. The first thing to be done, then, in 
the conduct of diagnosis, is to ascertain whether there are any 
local signs ; next to discover, whether any or all of them are 
sympathetic, and if so, of what primary affection, and lastly to 
consider whether the general and sympathetic symptoms cor- 
roborate our suspicions, that is, whether they can all be ac- 
counted for upon the supposition that we have found the local 

*Ata xivoaxu. I know through. 



40 DIAGNOSIS. 

cause, and whether any are absent which are uniformly or com- 
monly concurrent with similar conditions to those supposed to 
exist. 

It sometimes happens that diagnosis will detect disease in 
two or more organs simultaneously, or complication. 

It would of course be impossible for any man to conduct a 
diagnosis properly upon any case of disease unless he should 
be acquainted with diseased conditions generally, and particu- 
larly with the relations and sympathies of parts. The dental 
surgeon is not prepared to investigate symptoms occurring in 
the mouth until he can detect those which are sympathetic, and 
trace them to their source. Were he guided only by a promi- 
nent local symptom, he might make serious mistakes. For in- 
stance, a female may complain of violent pain in a tooth, 
which may in fact be entirely due to sympathetic connexion 
with the uterus, and not at all dependent upon any diseased 
condition of the tooth in which it occurs. 

The mode of distinguishing dental diseases and those of the 
parts adjacent to the teeth and mouth is fully set forth in works 
of dental surgery. We will, therefore, omit any particular 
directions upon this subject ; but we would earnestly urge 
upon every dentist to extend his knowledge until it shall em- 
brace the entire subject of diseases and their cure. 

Independently of the necessity of diagnosing the local affec- 
tions, it is always important to ascertain those conditions which 
are immediately represented by general symptoms: or more 
correctly, it is always important to ascertain how far the nerv- 
ous centers and vascular system are participating in a disor- 
der. A number of symptoms, very variable and difficult to be 
described, announce general nervous sympathy and the degree 
in which it exists, but the connexion of the vascular system 
with a diseased state, is for the most part determined by the 
pulse* i. e. by the beating of the arteries due to the propulsion 
of blood through them. 

The artery which is generally examined for this purpose is 
the radial, which is of sufficient size, and passing near the sur- 
face at the wrist is most conveniently situated for examination. 

* Pulsus.— Lat. 



DIAGNOSIS. 41 

The frequency, quickness, force or resistance, volume and any 
peculiar sensations given by the pulsation, are all subjects for 
observation, and contribute to the discovery of the nature, seat 
and degree of disease. 

Since the days of Galen, judicious and successful physicians 
have paid much attention to the pulse as a guide to correct di- 
agnosis and practice, and although it is too common in this 
day to hear this symptom decried as uncertain, yet the fact is, 
that to those who know how to interpret its communications, 
it furnishes the most valuable of all our means of diagnosis. 

In order to understand the morbid pulse, it is necessary to 
be well acquainted with its healthy conditions, for it is only by 
comparing its pulsations with the natural standard that we are 
able to detect morbid variations. 

The pulse differs in frequency at different periods of life. In 
infancy it is much more frequent than in mature life, and be- 
comes slower in old age. In infants* under two years of age 
the number of pulsations is above one hundred in a minute; 
in adult age, about seventy, and somewhat less in advanced 
life. These numbers, however, are susceptible of great varia- 
tion. Whylt mentions a case where a healthy woman had a 
pulse of one hundred and twenty ; and instances have been 
known where the natural pulse has amounted to only thirty-six 
or forty. The pulse of females is usually somewhat more fre- 
quent than that of men, and owing to the nervous sensibility of 
the gentler sex, is more readily excited by mental emotions, &c. 

The healthy pulse is accelerated by exercise, and mental ex- 
citement. It is often more frequent in the evening than in the 
morning, after a full meal, or the use of exciting drinks, and 
in pregnancy. It is also often very much accelerated after co- 
pious evacuations and under circumstances of great prostra- 
tion. It is diminished by the horizontal posture, by rest, by 
moderate bleeding, and by the influence of certain drugs, such 
as digitalis and the tartrate of antimony. 

•Some writers, as Billard and Valleix as«ert that the pulse of young 
infants is not near so frequent as is generally supposed. See Cliornel, Gen^ 
eral Pathology, p. 171. 
4* 



42 DIAGNOSIS. 

Indeed, the frequency of the pulse is subject in so great a 
degree to the control of idiosyncrasy* and accident, that no 
positive inferences can be drawn from this solitary symptom, 
unless the habitual pulse of the patient be known. Chomel 
says, "I have seen a lady whose pulse during the par- 
oxysms of intermittent fever did not beat above sixty per min- 
ute, to the great astonishment of her physician. This astonish- 
ment would have ceased had he counted the number of pulsa- 
tions during the intermission, these being not above forty per 
minute." Quickness and frequency are not synonymous terms. 
Frequency has reference to the number of pulsations in a given 
time, as a minute ; quickness to the time required for the 
completion of a single pulsation. Slowness is opposed to 
frequency, not to quickness. Thus we may have a slow quick 
pulse ; that is, one in which the beats in a minute are fewer 
than natural, but each particular beat is rapidly performed. 
For an opposite to quick, physicians frequently use sluggish or 
laboring. 

The natural pulse is soft or compressible : that is, it readily 
yields to gentle pressure with the finger. The hard pulse is 
the reverse, offering considerable resistance to the obliteration 
of its channel by pressure. Tense, wiry, firm, &c, are used 
to express modifications of hardness. 

Differences are also observed in the volume or size of the 
pulse. Sometimes it is full and open, at other times, small 
and contracted. It is called regular when the beats succeed 
one another in natural order, irregular, or interrupted, when the 
regular succession is broken by omissions of pulsation. 

Certain conditions, too, are attended with peculiarities of 
the pulse. In aneurism of the heart, or large arteries, it im- 
parts a peculiar thrilling sensation to the hand, which has more 
aptly, than is usual in such illustrations, been compared to the 
sensation which would be imparted by the passage of a fluid 
through a shattered quill. Ossification of the coats of the ar- 
teries destroys their elasticity, and of course renders the pulse 
very hard. The hard pulse is usually attended by a peculiar 
* Idiosyncrasy — tStoj avrxpoatj — peculiar constitution. 



DIAGNOSIS. 43 

condition of the blood, which when drawn and coagulated, 
presents a yellowish lymphy surface, which is called the buffy 
coat, with but few exceptions, a very important sign of inflam- 
matory action.* The following precepts for feeling the pulse, 
though very minute, are nevertheless worthy the attention of 
those who are inexperienced in it. Long habit imparts to the 
fingers an extraordinary accuracy of sensation in this respect- 
but until it shall be acquired, it is not easy to form correct con- 
clusions without all the care demanded by these rules. 

The physician should wait until the patient has recovered 
from the emotion produced by his presence, requesting him to 
preserve absolute silence, and to remain in the sitting or hori- 
zontal posture. v The pulse may be examined at the temples, 
lateral parts of the neck-, arm, thigh, wrist, and wherever the 
arteries are sufficiently large and superficial ; but the radial ar- 
tery is generally preferred at the place where it ceases to be 
covered by the muscles of the forearm, opposite the radio-car- 
pal articulation. If the patient be up, he should be placed in 
the sitting posture, if in bed, he should be upon his back, so 
that he may neither incline to the right or left, and thus impede 
the circulation of blood in the arteries. The arm should be 
placed nearly in a state of extension, and sustained in its 
whole length, so that the muscles may be relaxed. The fore- 
arm should be nearly prone, that it may, upon the cubital edge 
and the radial edge be a little raised. Care should be taken 
that no bandage or clothing impede the flow of blood in the 
axilla, at the elbow or any other point. All bandages should 
be removed so that there be the least possible compression. By 
means of these various precautions, we may be certain that there 
is no foreign obstacle to the flow of blood through this vessel. 

The artery of the left side should be felt by the right hand, 
and vice versa: the four fingers placed parallel on the same 
line, should be applied over the track of this vessel ; the index 
finger should be nearest the hand of the patient, and the little 
finger applied lightly, should be the first to receive the impulse 

* The buffy coat is also seen upon the blood drawn from pregnant fe- 
males. 



44 DIAGNOSIS. 

of the blood ; at the same time that the four fingers are placed 
over the radial artery, the thumb, or rather the palm of the 
hand should rest upon the dorsal face of the forearm, thus afford- 
ing solid support to the fingers by which the pulse is examined. 
The latter should at first receive a slight lateral movement in 
order to ascertain the situation of the vessel. When the fin- 
gers are all placed upon the artery, the pressure should be 
gradually increased and diminished several times in succession, 
so as to appreciate the influence of the pressure upon it, and 
thus more easily ascertain its different qualities. Twenty or 
thirty successive pulsations should in this manner be examined. 
It is not without advantage to examine the pulse in the two 
arms alternately, or at once : it should also, in particular cases, 
be examined in other places wherever it may throw light upon 
the diagnosis. It may be also examined several times, or at 
least a second time, before leaving the patient. However mi- 
nute these precepts may appear, they cannot be neglected 
without inconvenience. — Chomel, Elem. General Path. 

The inferences of pathological conditions to be drawn from 
the several above mentioned differences of the pulse, will be 
explained, as far as the purpose of this treatise requires, when 
we come to treat of particular diseases. 

Pain is one of the most common and important symptoms 
of disease. It is this which usually gives the first intimation 
of disorder, and drives the patient to medicine for relief. It 
is very important that the physician and surgeon should know 
how to interpret this sign, and in order to this, much general 
knowledge of parts and symptoms is necessary. 

An uninstructed observer naturally infers that the pain is 
always felt in the part diseased, and that its intensity accu- 
ratelyrepresents the degree of the disorder. 

But such prima facie opinions are often very erroneous. We 
have already remarked, that a part may sympathise with a local 
disease seated in a distant and dissimilar organ. It also hap- 
pens frequently, that diseases of the nervous centers, and of 
the nerves themselves, occasion pain at the extremities of these 
organs of sensation, instead of at the point actually attacked. 



DIAGNOSIS. 45 

Violent pain in the nerves of the face may depend upon dis- 
ease located in the brain or intermediate parts ; and similar 
conditions are noticed in other nerves. 

Nor does the degree of pain represent necessarily the de- 
gree of the disease which causes it. Some parts are much 
more sensitive than others, the most important organs being 
least sensitive. The quality of sensation does not necessarily 
belong to living bodies, but is distributed to the several parts, 
arbitrarily, yet with wonderful wisdom and mercy. Pain is 
intended to warn us of danger and compel us to preserve the 
integrity of the body ; it is therefore set as a sentinel chiefly 
upon the out-posts of life. The external surfaces being much 
more sensitive than others. Those most carefully protected, 
being least profusely endowed with this watchful property. 
Hence it happens that the brain, heart, and lungs may be very 
seriously diseased without causing much, or indeed, any local 
pain, while an unimportant injury to the eye or skin will cre- 
ate great distress. 

The nature of the disease may often be guessed from the 
character of the pain, as it is burning, scalding, fixed, fugi- 
tive, darting, throbbing, &c. As pain does not point out with 
certainty the seat of the disease, and as its intensity does not 
necessarily indicate the degree of the change producing it, 
neither does its abatement or disappearance prove the 
relief or cure of the disorder. In many instances it certainly 
does so, but very often it does not. 

Pain may be lulled by the action of causes which lessen the 
sensibility, as by narcotic medicines, by the exhaustion in- 
cident to protracted sufferings, by morbid conditions of the 
nervous centers, or the nerves themselves, or by absolute loss 
of vitality. It sometimes happens that the sudden cessation 
of violent pain is a most fatal symptom, as showing that morti- 
fication has occurred in the diseased part. 

Pain is often intermittent and disappears only in obedience 
to a law of disease, not of health. 



CHAPTER V 



TREATMENT OF DISEASE. 



The first step towards the cure of disease is to remove the 
cause which has produced it. Unless this can be done, we 
must be very much embarrassed in our efforts to relieve, inas- 
much as the morbid conditions are continually liable to renewal. 
The impracticability of doing this effectually, forms the most 
serious obstacle to the successful treatment of many disorders. 
Children teething during very hot weather are subject to the ac- 
tion of combined causes, which often induce diseases which are 
very serious and very difficult to be controlled, while the causes 
continue to act. Dead teeth remaining in the mouth may pro- 
voke a series of unpleasant and even dangerous evils, which 
cannot be removed while the cause of them remains. 

It must not be supposed, however, that the removal of the 
primary cause of the disease will necessarily procure the sub- 
sidence of the disease itself. If a man pierce his flesh with a 
thorn, the wound will remain and may give great pain after the 
foreign body has been extracted ; the effects of a wound from 
a bayonet or musket ball may manifest themselves in serious 
and fatal disease long after the instruments of the injury have 
been withdrawn. The same truth holds good in all kinds of 
injuries by whatever class of agents they may be produced. 

The absolute rest of a diseased part, when the nature of its 
function permits, and the least possible exertion of others, is 
very conducive to cure. 

There are, however, certain exceptions to this rule. Certain 
morbid conditions of the articulations are improved by exer- 
cise ; a particular mode of ocular affection requires the light, 
&c. — but the exceptions are few and the rule general. 



48 TREATMENT OF DISEASE. 

The regimen of the patient, that is his diet, clothing, exer- 
cise, employment, &c, require judicious management. 

Finally, the most important part of treatment consists in the 
skilful application of therapeutical agents, and surgical means; 
but of this part of the subject we will treat particularly when 
considering special diseases. 



CHAPTER VI. 



NATURE OF DISEASE. 



Many of the morbid alterations which seem to constitute dis- 
ease, or to cause symptoms, have been observed upon the living 
and the dead subject: many others have as yet escaped detection. 
We are unable, therefore, to compose a full list of these differ- 
ent conditions of parts, but those which are of common occur- 
rence, and are well ascertained, may be described as follows : 

1. Redness, swelling, and loss of cohesion of tissues. This 
is the most common of all modes of alteration, and is the cause 
of a large part of the disorganizations observed in tissues : it 
is called inflammation* The local symptoms of this condition 
are heat, redness, swelling, pain, and diminished, altered or 
suspended function. The general symptoms are pyrexia, or 

fever, of a particular type, seemingly connected with altered 
state of the blood. 

2. Stuffing or engorgement of the veins, or congestion. The 
symptoms are not so well defined as in the first kind of affec- 
tion. The local suffering is generally much less, though when 
certain organs, such as the brain and heart are the seat of con- 
gestion, the pain and discomfort are often very considerable. 
The function of the congested organ is greatly embarrassed or 
altogether suspended. The general symptoms are generally 
such as mark diminished action. 

3. Red indurations ; vegetations ; fungi, polypi. 

* rivp fire — from the burning sensation and heated appearance of pa- 
tients in fever. 

5 



50 NATURE OF DISEASE. 

4. Vesicles, pustules, suppuration, erosion, ulceration, per- 
foration, gangrene. 

5. Thickening, granulations, thickness of tissues naturally 
transparent, adhesions, effusion of serum, false membranes. 

6. Conversion of one tissue into another. 

7. Gray induration, gelatinous degeneration, tubercles, ence- 
phaloid matter, cancerous matter. 

8. Contraction, dilatation and complete obliteration of nat- 
ural canals. 

9. Accidental canals, fistulas, accidental tissues, cysts. 

10. Development of gas in cavities. 

11. Living bodies in organs. 

12. Effusions of blood, collections of blood. 

14. Chalky, stony, hairy, horny, and melanotic* produc- 
tion. 

15. Changes of form and relation, wounds, ulcers, disten- 
sion, lacerations, ruptures, fractures and dislocations. 

16. Foreign bodies. 

17. Vices of formation. f 

The fluids of the body, especially the blood, are doubtless 
capable of undergoing change primarily, and communicating 
distress and disease to other parts. But the pathology of the 
fluids is but very little understood. The same may be said of 
the nervous matter, of the nature of which we know nothing. 

The above catalogue is therefore very defective, as it takes 
no notice of some of the most common and most important of 
all diseases, such as fever ; and describes as diseases, condi- 
tions, which are only incidental to other previous and more 
important phenomena. Nevertheless, it is as accurate, or 
nearly so, as the present state of medical science will permit. 

It is my purpose to select from this list such pathological 
conditions as are particularly connected with the pursuits of the 
dentist, omitting none, which, even in a remote degree, con- 
cern him, and passing by those in which he has no profes- 
sional interest. 

* Mttoj — black. fRoche &. Sanson. Path. Med. Chir. 



NATURE OF DISEASE. 51 



Inflammation. 

The most common, and for several reasons the most import- 
ant of all morbid conditions, is one which is characterized by 
redness, swelling, pain, and increased heat. This is called 
inflammation, and may occur in any parts naturally possessing 
sensibility. Alteration or suspension of the natural secretions 
is a constant attendant upon inflammation, and when seated in 
organs which do not secrete it, arrests, or more or less embar- 
rasses, the performance of their functions. The redness of an 
inflamed part is caused by the presence of red globules in 
small vessels which naturally carry only the serous or white 
part of the blood, and frequently, in addition to this, to the 
escape of blood from ruptured vessels and its deposit in sur- 
rounding tissues. This is called chemosis, or ecchemosis* 

The presence of red globules in the serous vessels, or capil- 
laries seems to be the essential fact in inflammation; the other 
phenomena being apparently consequent upon this error of cir- 
culation. It has hence been the anxious desire of pathologists 
to ascertain the cause of this irregularity in hope that such 
knowledge might lead to more sure modes of relief. It is not 
my purpose to recapitulate the several theories, which have 
been constructed by learned and ingenious men, in order to 
explain the phenomena of inflammation. The condition thus 
named is compatible with very different states of the general 
system and also of the tissues immediately concerned, and 
therefore no statement of the pathology, and no plan for treat- 
ing this form of disease can be uniformly correct. All patho- 
logical conditions attended by heat, redness, swelling, and pain 
are considered inflammatory, whether the parts immediately 
concerned be in a sthenicf or asthenic state. 

Theorisersupon inflammation have been much perplexed to re- 
concile the distension of the capillaries with the apparently exci- 
ted state of the parts : for distension or yielding of the walls of 
the vessels being connected in their minds with the idea of force 

* Ex, out of. X^oj, humor, f 1Qtvo$, strength. 



52 NATURE OF DISEASE. 

overcome, or of relaxation, they suppose, that in inflammation 
the capillaries are less active and resistent, or in other words, 
comparatively passive; such being the case, it appears ra- 
tional to use exciting applications in order to arouse the ca- 
pillaries to exertion, so that they may empty themselves of su- 
perfluous blood, and resist the influx of unusual quantities of 
that fluid. The fact is, however, that the capillaries expand 
when excited, and thus draw to themselves an additional 
amount of blood, by a simple hydraulic law. They are not pas- 
sive, because distended ; but are distended in consequence of 
activity. Familiar examples will show the truth of this 
opinion. If the cheek be held close to a burning body, the 
skin will be reddened ; in other words, the effect of the stim- 
ulus will be to dilate the capillaries, and attract to them a large 
volume of blood, suffering red globules to enter their canals. 
On the other hand, if cold water or ice be applied to the skin, 
it grows pale and shrinks, showing the contraction of the ca- 
pillaries when their activity is diminished. The erectile tissues 
furnish us with an example of the operation of a similar law. 

The swelling of an inflamed part depends upon the presence 
of an unusual amount of blood in it, and upon the effusion of 
serum, blood, or lymph, or pus, consequent upon the engorge- 
ment. 

The cause of the pain in inflamed parts is not very plain. 
At first sight it might appear to be due to the mechanical dis- 
tension, but a moment's reflection will enable us to perceive 
that such cannot be the cause, for we may subject healthy 
parts to engorgement and distension, causing redness and 
swelling without pain. A string tied around the finger will 
cause the extremity of the organ to swell exceedingly, and be- 
come lividly red, yet this condition is not attended with pain, 
while inflammation of the same part is extremely agonizing. 

The pain of inflamed parts is so much modified by peculiar- 
ity of structure as often to enable the observer to distinguish 
the seat of the disease by the character of its sensation. As 
a general rule, the external parts are the most sensitive. The 
skin when inflamed is affected by a burning or scalding sensa- 



1 



NATURE OF DISEASE. 53 

tion, often intermingled with itching, even more distressing 
than the burning itself. The inflamed mucous membrane par- 
takes of this sensation, though generally in less degree, unless 
in superficial situations. 

The serous membranes when inflamed, cause a sharp darting 
lancilive pain. The pain of the cellular membrane under sim- 
ilar circumstances, differs very much according to its position 
and relations. When in connexion with the skin, it partakes 
of the pungency which characterizes the inflammation of that 
sensitive organ ; when the cellular structure of the internal 
viscera is inflamed, the pain is usually dull, or obtuse, in con- 
sequence of the manner in which these viscera are supplied 
with nerves. 

When nerves are the seat of inflammation, very acute, dart- 
ing pangs are felt, and the surrounding structures are generally 
very sore, tender, and more or less inflamed. When the mus- 
cles are inflamed, the sensation is aching, mingled with a feel- 
ing of fatigue. The pain is greatly aggravated by motion. 
Inflammation of ligaments and bones, causes sensations not 
very different. 

Pain is more or less severe in proportion to the degree of 
the inflammation, and is also much modified by peculiarities 
in the nature of the disease, and the condition of the parts 
affected. Certain specific affections, such as cancer, occasion 
a peculiarly distressing, darting, and burning pain : slight in- 
flammation of the pulp of a tooth produces intolerable agony, &c. 

Pain does not always proceed from inflammation : it may 
attend very opposite conditions. Ice held upon the skin will 
cause great suffering. 

The secretions of organs are very materially modified by in- 
flammation. If it be slight, the natural secretion may be 
slightly increased, more often with increased secretion there 
will be an obvious alteration of it. Sometimes it is thinner 
and acrid, reddening, or excoriating the parts over which it 
flows : sometimes it is thicker, and more tenacious, often, es- 
pecially if the inflammation be severe, it is much diminished, 
or altogether suspended. An abundant discharge of thickened 
5* 



54 NATURE OF DISEASE. 

secretion often precedes, and seems to be the means of relief 
of the inflamed parts. 

It has become common to designate inflammation of the 
different parts by attaching the common termination "Ms" to 
the Greek name of the part affected. Thus, stomatitis indi- 
cates inflammation of the atopa, stoma, or mouth — gastritis, of 
the yaatpov, gastron, or stomach. Sometimes the suffix is 
added to a latin name, as conjunctivitis ; in some instances, 
terms descriptive of inflammation, have become so firmly fixed 
in our nomenclature as still to be continued, though as excep- 
tions to the rule. Thus, pneumonia signifies inflammation of 
the lung ; rheumatism, of the muscles. The term myitis is 
sometimes used instead of rheumatism. 



The Consequences of Inflammation. 

Inflammation never continues long without the supervention 
of certain results, often of greatly more importance than the 
phenomena we have described. When it passes away with- 
out consequences, we call the process resolution. 

The consequences, or as they are sometimes considered, the 
accidents of inflammation, vary according to the degree of its 
violence, the nature of the part, the general health of the pa- 
tient, &c, &c. 

The consequences of inflammation are chemosis, oedema, 
suppuration, vesication, ulceration, permanent alteration of 
texture, caries, and gangrene or mortification, or the absolute 
death of a part. Sometimes, also, by the effusion of a plastic 
substance, called lymph, adhesion is formed between surfaces, 
naturally, or artificially, separate ; but as this adhesive inflam- 
mation is more often a reparative and conservative than nox- 
ious process, we will not include it among the consequences 
before mentioned. ' 

Chemosis is the extravasation of blood in the progress of 
inflammation. This is not a mere mechanical fact, for the 
blood under these circumstances is evidently changed from its 



NATURE OF DISEASE. 55 

ordinary condition. It is no longer coagulable, and remains 
in the tissues into which it has escaped until absorbed ; which 
is often a very slow process. 

(Edema is the extravasation of the serum or watery parts 
of the blood. It is apt to attend debilitated conditions and 
seems to mark a lax condition of the coats of the vessels by 
which it is exuded. It is generally found in loose cellular 
structures, where the looseness of tissue affords little support to 
the walls of the vessels. It often attends a very low degree of 
inflammation, in debilitated subjects, and is unfavorable to re- 
covery ; rather as a sign of debility than from any evil which 
it is likely to cause. (Edema may exist without inflammation, 
as when the veins fail to return their blood in due proportion 
to the rapidity of their supply, either because of mechanical 
pressure, disease of the heart, or any other cause. (Edema 
also attends certain specific conditions, as scarlet fever, and 
may be produced by medicinal agents, as arsenic. When 
cedema is general, it is called "anasarca."* It is readily de- 
tected by the bloated translucent aspect of the skin, and by 
its loss of elasticity observed by its pitting under pressure. 

Vesication, or blistering, is the effusion of serum under the 
cuticle and rete mucosum, elevating them above the level of 
the surrounding surface, and separating them from the cutis 
vera. This may occur as the result of topical applications of 
an irritating kind, or, in consequence of local or constitutional 
disorders. This condition is frequently produced as part of 
medicinal treatment, and gives the name of vesicatories to a 
class of means employed for this purpose. 

Suppuration, or the formation of a peculiar fluid substance 
called pus, is one of the most common and important of the 
consequences of inflammation. 

Pus, when pure, is a thick cream-like yellowish, of a faint 
and peculiar odor, and somewhat sweetish of taste. It is not 
at all irritating. To this kind of pus, the term laudable and 
healthy have been applied. That which is thin, dark, and irri- 

•Am aapf — throughout the flesh. 



56 NATURE OF DISEASE. 

tating, being considered unhealthy, because of the indication 
it affords of the bad condition of sores, &c. which secrete it. 

Although it is true that such pus as is called ''healthy," in- 
dicates a convalescent state of an ulcer, or abscess, yet the in- 
ference to be drawn from its appearance attaches exclusively to 
the parts which secrete it : while it may herald the abatement 
of local inflammation, it may, nevertheless, give clear evidence 
of a state of disease incompatible with the integrity of organs, 
or with life itself. Suppuration of the eye, of the liver, or of 
the lungs, would be a very serious matter, however "healthy" 
the pus might be. 

Some writers have considered suppuration a curative process, 
and have regarded the pus as a very valuable covering for the 
granulations. 

Although it is true that suppuration often intervenes be- 
tween inflammation and cure, and that the painful symptoms 
of inflammation abate or disappear after the copious secretion 
of pus, yet we must regard the formation of this matter, how- 
ever pure, as a great evil, though certainly preferable to others 
which occasionally affect inflamed parts, and it is one of the 
greatest cares of the surgeon and physician to prevent it. 

Pus may form in several situations. First. It may be found 
free upon the inflamed surfaces of parts, as the skin, the 
eye, and mucous membranes, without any other apparent 
change of organization than an increase of the natural vascu- 
larity. Secondly. On the naturally unexposed surfaces of the 
body after they have acquired a new organization, by increase 
of red vessels, and usually, if not always, by the addition of 
coagulable lymph ; for it may be questioned, whether in any 
instance the surfaces of the cellular, synovial, serous, and 
medullary membranes, the pia mater, or periosteum, can furnish 
genuine pus, without the deposition and organization of some 
coagulable lymph. 

The third situation in which pus is generated is the surface 
of the peculiar structures, called granulations, the vascularity 
of which exceeds that of all the natural surfaces of the body. 



NATURE OF DISEASE. 57 

The pus formed on the granular surface of an ulcer is the best 
example of this kind.* 

Some parts of the body have a much greater disposition to 
form pus when inflamed, than others. The cellular tissue, 
skin, and mucous membrane are very prone to suppurate, 
while the fibrous tissues manifest no disposition to it. 

Pus is modified by the nature of the part where it is formed, 
by the constitution of the individual, by various accidents, 
occurring in the process of its formation, and by certain ob- 
scure laws which control the phenomena of those affections, 
which are called specific. It will also present different ap- 
pearances, as it may be mixed with other fluids, as blood, 
saliva, bronchial mucous, &c. 

If pus mixed with blood, serum, &c, be long confined 
under dressings, or in cavities, it becomes very offensive, and 
often irritating. If it be produced from the irritation of diseased 
bone, it is also very fetid. When thin, mixed with blood, 
and evidently "unhealthy" it is called "sanies." 

When pus is irritating, it is so, not to the surfaces which 
secrete it, but to the adjoining healthy structures over which it 
flows. 

Pus is heavier than water, and this quality frequently ena- 
bles us to distinguish it from mucus. It is coagulable by 
muriate of ammonia, which Mr. Hunter considered a peculi- 
arity sufficiently marked to distinguish it from mucus, and all 
other natural secretions, but the accuracy of the test is disputed. 

From the fact that hard inflammatory tumors in the course 
of inflammation become soft and yielding, and filled with pus, 
it was naturally supposed that the original solid parts were 
converted into this fluid. It is now well ascertained that such 
is not the case, but that pus is secreted by the arteries. 

When pus is enclosed in a cavity formed in the progress of 
inflammation, the condition is called abscess. f 

The phenomena of abscess are very curious, and through 

* Macartney on Inflammation. 

t Abscedo — I depart, denoting the loss of substance. 



53 NATURE OF DISEASE. 

them, nature succeeds in relieving the body of foreign mat- 
ters, and repairing extensive injuries. 

When a part capable of suppuration is subjected to inflam- 
mation of the required intensity, some of the small vessels 
give way, and blood is effused into the surrounding parts 
Simultaneously with this rupture, or nearly so, the arteries be- 
gin to throw out a peculiar plastic matter, which is called co- 
agulable lymph. This is capable of becoming organized, and 
being thrown round the diseased parts, and between them and 
those which are healthy, it forms a barrier to the infiltration of 
extravasated fluids. By some strange process, to us altogether 
inscrutable, the walls of lymph become vascular, and capable 
of performing the vital functions of secretion and absorption, 
and by them the pus is furnished. As this secretion proceeds, the 
previous contents of the abscess, including the effused blood, 
are gradually absorbed, and fresh pus deposited in their stead, 
so that, if the tumor be opened at an early stage, the pus will 
be more or less mixed with blood, but if the opening be de- 
layed, the cavity will be found to contain only pure pus. The 
process of suppuration is announced by some relief of local 
symptoms, and a change in the character of the pain. It 
loses its burning sensation and becomes throbbing, at the same 
time, the tumor becomes softer, and at last fluctuates readily 
under pressure of the fingers. Very often, and especially 
when the disease is extensive, or when it is seated in the vis- 
cera, the formation of abscess is announced by shivering or 
chill. 

While the arteries of the walls are depositing the pus, 
other processes equally obscure are moving the abscess towards 
the surface, and preparing for its evacuation. The bottom of 
the cavity is constantly contracting and filling up, while the 
opposite side is thinning and expanding. The absorbents at 
one side of the abscess are busily engaged in removing mat- 
ter, while the arteries at the other, are as actively supplying 
new material ; at the same time, a temporary organ, made for 
the occasion, faithfully performs its peculiar functions, supply- 
ing pus, and removing mixed fluids from the cavity. 



NATURE OF DISEASE. 59 

The parts laying upon the summit of the abscess are rapidly 
thinned, the tumor is pushed towards the surface, the skin ul- 
cerates, an opening is made, and the pus evacuated. Though 
an abscess may discharge itself any where, there is evidently 
a strong disposition in such tumors to find their way to the out- 
side of the body. In order to effect this, they will often tra- 
verse dense opposing structures when a nearer opening through 
more yielding tissues might readily be effected. Sometimes 
when an abscess occurs in an important viscus, artificial adhe- 
sion will be formed between its surface and an adjoining struc- 
ture, and a continuous canal being pierced through, then the 
pus will be ejected upon the surface of the body, or into an- 
other organ which has external communications. 

These most curious and interesting facts are so conclusive 
of wonderful design and contrivance, that it is impossible to 
regard them in any other light than as manifestations of divine 
and superintending Providence. 

Foreign bodies are removed precisely in the same way as 
pus. When the abscess has reached the surface, a thin point 
appears, which is soon perforated by a very small opening 
through which the pus slowly oozes. The appearance of this 
thin projecting spot is called "pointing." 

Sometimes the parts which surround the abscess are too 
dense to permit the passage of the matter. When this is the 
case, great pain is often caused by the pressure, and the irrita- 
tion produced by the vain efforts of nature to relieve the parts 
may occasion very serious disease in adjoining structures. In 
some instances of this kind, as in abscess of the gums, or 
gum-boil, the pus failing to be evacuated, is ultimately ab- 
sorbed. 

When the attempt is made to form an abscess by weak or 
scrofulous constitutions, and in situations where the cellular 
substance is lax, the progress of the disease is very different. 
The first extravasation is serum, which passes easily into the 
loose cells of the cellular membrane with little or no injury to 
their structure. The parietes of the tumor are not composed 
in the beginning of organized and vascular lymph ; no genuine 



60 NATURE OF DISEASE. 

pus, therefore, is found in such cavities in the first instance ; 
the fluid they contain is serous, mixed with coagulable lymph, 
parts of which are found as flakes floating in the serum. As 
the cavities of chronic abscesses are not provoked, either by 
severe tension, or the quality of the contained fluid, there is 
no preparation made for some time to remove their contents. 
These collections, therefore, often traverse a considerable dis- 
tance along muscles, or under plates of fascia, before they ar- 
rive at the skin, which ulcerates very slowly ; after which, the 
cavities may inflame, their interior surface become more highly 
organized, and secrete genuine pus.* 

Ulceration is the process by which solutions of continuity 
are affected by vital processes and open secreting sores pro- 
duced. Inflammation is by no means necessary to this result, 
and some of the best writers upon pathology have declined to 
recognize it as one of the consequences of inflammatory action. 
Nevertheless, as ulceration does frequently occur in the progress 
of inflammation, and is an evil to be guarded against by the 
dental practitioner especially, it seems proper to consider it 
in this connexion. 

The process itself, is very curious, and at first sight, the 
facts explanatory of it are hardly credible. It is not easy to 
comprehend how a body can destroy itself and take itself 
away ; and the difficulty is not solved by the fact, that only 
small portions are thus removed. Yet, there can be no doubt 
that such is the case, and we may silence, if not satisfy, the 
objector, by suggesting the equal difficulty of understanding 
how parts form themselves ; both facts, as Mr. Cooper ob- 
serves, are equally well confirmed. 

Every part of the body is continually undergoing waste and 
reparation. It seems that the molecules of tissues are con- 
stantly becoming effete, and having undergone some mys- 
terious change, are taken up by the absorbents and carried off 
to the several waste gates of the system, from which they are 
ultimately discharged. The bowels, the kidneys, the skin, the 

* Macartney on Inflammation. 



NATURE OF DISEASE. 61 

lungs, all the emunctories are continually at work, and all ulti- 
mately discharging the debris of the system. 

At the same time that this disintegration is going on through 
the action of the absorbents, another set of vessels, the nutri- 
tive arteries, are every where depositing new matter. Bone 
receives bone, muscle is supplied with muscle, and viscus with 
its peculiar organic matter, so that the integrity and form of 
each part, and of the whole, are exactly preserved. By some 
wonderful and inscrutable law, the balance of supply and de- 
mand is equally adjusted, yet not so positively as to lead us 
to infer that the action of the one set of vessels regulates that 
of the other. In childhood, the supply exceeds the waste, and 
the body grows ; in maturity, the supply is regulated more by 
the wants of the man than the activity of the absorbents. If 
his vocation calls for increased strength of arm, the very use 
of the organ, instead of consuming, augments its volume. 

In truth, the two sets of vessels seem to be independent of 
one another, yet, like other parts, they naturally work together 
for the production of the phenomena of life. 

It will readily be perceived that if any circumstance should 
increase the activity of the absorbents of a part beyond what 
is usual, and should not simultaneously stimulate the nutritive 
vessels: or, should any circumstances render parts unusually 
susceptible of absorption, that the result would necessarily be 
an obvious loss of parts, and the interruption of their conti- 
nuity. It is also obvious that the converse of these condi- 
tions would be attended with similar results ; for if nutrition 
be impeded, either through defect of supply, or any cause ren- 
dering the part less capablethan usual of converting blood into its 
own tissue, loss of volume, andbreach of continuity might occur. 

Ulceration may result from any of these causes. Pressure 
is a common cause of ulceration, and acts probably by inter- 
rupting the circulation, and nutrition of a part. Pressure 
may produce absorption and waste without causing ulceration, 
and the dentist when fixing artificial pieces in the mouth must 
be careful so to adjust his plates and springs as to avoid both 
of these evils. 
6 



62 NATURE OF DISEASE. 

Inflammation probably produces ulceration in a manner 
somewhat similar; viz. by causing such impediment to circu- 
lation, as prevents nutrition from being properly performed. 
It is also probable, that the blood itself, undergoes changes 
under the influence of inflammation, which render it less ca- 
pable of supplying the loss of parts. 

Diseased parts, and those which from any cause have be- 
come useless, and these only are liable to be wasted by absorp- 
tion. Unhealthy products, such as fungus,* are often removed 
with wonderful rapidity, and even bone will be removed when 
being no longer needed, it has become foreign matter. The 
roots of the deciduous teeth are thus entirely removed, and the 
dead fangs of permanent ones are subjected to continual waste 
from the same cause. That they are not entirely removed, is 
due to the comparative shortness of time which the present 
term of human life allows for the process, rather than to any 
resistance they are able to offer to the action of these all-sub- 
duing lymphatics. 

Extraneous substances are generally removed by ulceration. 
Thus, a ligature will be separated from an artery, or a foreign 
substance from a wound: no more of the surrounding substance 
being absorbed than is necessary to loosen and dislodge the 
intruder. 

By ulceration, also, dead parts are separated from the living, 
and the decomposed fragments removed to make room for new 
matter. 

Sometimes ulceration seems to produce great devastation, 
and is then called phagede?iic.\ In such cases, it is evident 
that the ulceration is only the consequence of the destruction, 
not the cause, for, until the parts have become too much enfee- 
bled to subserve their natural purpose, they will not be sub- 
ject to this rapid absorption. 

Adhesion is often consequent upon inflammation, though 
like ulceration, it is not always dependent upon inflammatory 
action. It is a process by which nature unites parts, either 

* #oy« — I eat. f Fungus— a mushroom — proud flesh. 



NATURE OF DISEASE. 63 

naturally, separate, or artificially divided. The bond of union 
is coagulable lymph. 

This process is of immense importance, in checking hem- 
orrhage, closing fissures, and in providing means of safe transit 
for pus, from the viscera to the surface. 

Both of these processes are sanitory. Mr. Hunter calls ul- 
ceration the natural surgeon, and declares that even in the 
spreading of an ulcer, there may be considerable advantage ; 
and another writer very properly observes, that the same re- 
mark would apply to the effusion of lymph. The one acts 
like the surgeon that unites parts ; the other like the one who 
removes them, because they are not fit to remain ; and it would 
not appear more justifiable to call adhesion and ulceration in- 
flammatory processes, than to consider the operations of sur- 
geons themselves as particular modes of inflammation. 

Inflammation may result in a permanent change of struc- 
ture. Parts may become denser and harder, or, indurated; 
sometimes certain structures under the influence of slow in- 
flammation are softened : sometimes a permeable cellular struc- 
ture, as the lungs, becomes changed into a dense impermeable 
structure, like liver, or hepatized :* and sometimes accidental 
inflammation begets, in persons and parts inclined thereto, mor- 
bid growths of a specific character. 

The most disastrous result of inflammation is the absolute 
death of a part, reducing it to the condition of a foreign body, 
and subjecting it to the play of chemical affinities. 

When this takes place in soft parts, it is called gangrene or 
mortification ; in bones, necrosis. The dead soft parts, when 
separated by ulceration from its connexion with living parts, 
is called sphacelus,! or slough, a fragment of dead bone is 
called sequestrum.:}: 

Caries is a condition of bone somewhat analogous to ulcer- 
ation of soft parts. Caries of the teeth is the result of chem- 
ical agents acting from without, and decomposes their struc- 
ture, they are, however, subject to necrosis as other bony tis- 
sues, and the fact of their being liable to a peculiar erosion, does 

# Hepar — the liver. + 2<f>af« — I destroy. X Sequestro — I separate. 



64 NATURE OF DISEASE. 

not probably exempt them from the kind of caries observed in 
similar structures. If such idiopathic caries does occur in the 
teeth, it must be very rare, and is always confounded with 
the erosive caries peculiar to these structures. 



Inflammation of the several parts composing the Mouth, and 
of the parts adjacent. 

The mouth is very complicated and exquisitely organized. 
It subserves a variety of very important purposes. Speech, 
mastication, insalivation, taste, inhalation, and expiration, 
are all performed in this small, but admirably constructed cav- 
ity. Such numerous and complicated functions require the 
presence of various and delicate organs closely packed togeth- 
er, and a large endowment of nerves and blood vessels. 
Glands are hidden in every part of the walls of the cavity, 
their ducts perforate its floor, and open on its sides; nerves 
and blood vessels of extraordinary size creep along every 
bony channel, and spread in expanded network over the whole 
surface, while the mucous membrane with its innumerable crypts 
and follicles covers the whole, and connects every sentient part 
with the sympathies of the external and internal surface. 

Into the cavity thus constructed, and thus exquisitely en- 
dowed, air of different temperature is constantly rushing ; food 
and drink of various kinds are received ; secretions are poured 
out, remains of aliment and of the natural fluids undergo 
change, and medicinal agents of various kinds are made to 
pass. 

Besides all this, the mouth is the seat of the extraordinary 
process by which two sets of teeth are matured and evolved, 
and one of them removed by a physiological, and the other, to 
a greater or less extent, by a morbid disintegration. Under 
these circumstances, it is not wonderful that inflammation fre- 
quently occurs in the mouth, and that it should be attended 
there with severe suffering. 

As the cellular tissue enters largely into the composition of 



NATURE OF DISEASE. 65 

the structures of the mouth, the form of inflammation most 
common in that cavity, is what is called phlegmon.* 

Phlegmon is the common form of healthy inflammation in 
organs composed largely of cellular tissue. It generally re- 
sults from some local cause, as a blow, pinch, or other me- 
chanical injury, or from the irritation of acrid matters, or for- 
eign substances. Sometimes, however, it depends upon con- 
stitutional causes. 

When phlegmon is seated in the subcutaneous cellular tis- 
sue, it presents a hard circumscribed red tumor, which is gen- 
erally very painful. At first, the sensation is burning and dart- 
ing, subsequently as the tumor softens, throbbing, or pulsating. 
After a longer or shorter time, according to the intensity of the 
inflammation and nature of the affected parts, fluid is felt to 
fluctuate in the tumor; in other words, an abscess, filled with 
pus, has been formed, the skin ulcerates, the matter is dis- 
charged, and the cavity is obliterated. 

What is called a boil is the best example of genuine phleg- 
mon. It is a possible thing for a phlegmon to terminate natu- 
rally by resolution, but this very rarely happens, unless the in- 
cipient inflammation be actively combated by the resources of 
art. In by far the greatest number of cases the best treatment 
fails to prevent suppuration, after the phlegmonous tumor has 
been fairly formed. 

Circumstances of position may vary the phenomena of pleg- 
mon. If it be seated in important viscera, the constitutional 
symptoms will predominate very remarkably over the local dis- 
tress : if it be formed under aponeuroses or muscles, the ten- 
sion occasioned by the resistance of these unyielding tissues 
greatly aggravates the pain while it prevents the swelling. 
The matter not being able to escape is extravasated among the 
adjacent tissues and communicates irritation, and inflammation 
as far as it reaches. Ultimately an opening may be made at a 
distance from the seat of the abscess : the pus may traverse 
a tortuous channel, the cavity not being properly emptied, may 
first heal, and a sinus, or sinuous ulcer, may be the consequence. 

* Phlegmon — ^Xtyui, phlego, I burn. 



bb NATURE OF DISEASE. 

The pathological characteristic of phlegmon is the effusion 
of coagulable lymph, by which the inflamed parts are walled 
in, and the pus confined within the cavity and made subject to 
those obscure and curious processes by which it is ultimately 
evacuated. It is this limitation which gives to phlegmon its 
hard resisting character, and which by impeding the circula- 
tion, causes the deep red hue which does not disappear upon 
pressure. To the same distension of vessels is due the pecu- 
liar pain of these inflammatory tumors. 

There is another form of inflammation which differs, m some 
important particulars, from phlegmon, and is called erysipelas. 

This form of disease is peculiar to the skin, and mucous 
membrane, and is far most usually met with in the former or- 
gan. It differs from phlegmon, particularly in this, that it is not 
circumscribed by lymphy barriers, but is diffused until gradually 
lost in healthy parts. The effusion which occurs in erysipelas is 
serous. When the skin only is affected, the serum is effused un- 
derthe cuticle, and occasions vesications. Sometimes thecellular 
tissue beneath the skin becomes inflamed together with it, and 
putting on its own phlegmonous condition, though imperfectly 
developed, forms a compound disease, which has been called 
phlegmonous erysipelas. The effused serum, and unhealthy 
pus, diffused through the loose cells of the cellular tissue, carry 
destruction to this substance, far and wide, among the muscles 
and beneath the skin, while the latter organ ulcerating, and 
sloughing rapidly, gives way before the advancing inflammation. 

This aggravated affection takes place in persons of debilitated 
constitutions, and as the result of wounds, and specific poisons. 

In erysipelas, the circulation of the skin is not impeded, and 
therefore the pressure of the finger on the skin temporarily res- 
olution moves the red color. The pain is burning, or stinging. 

Simple erysipelas does not tend to form pus, but ends by res- 
tion or effusion. The constitutional symptoms attending it, 
are generally much more serious than those resulting from 
phlegmon. 

* Eptw — I draw. lltXai, near — from the tendency to involve surround- 
ing pans. 



NATURE OF DISEASE. 67 

Sometimes this form of disease occurs in the mouth, as the 
consequence of wounds, and even as an idiopathic affection. 
Sudden death is sometimes produced by the effusion of serum 
about the glottis — as the result of erysipelas affecting the la- 
rynx. This affection is called oedema of the glottis. 

Phlegmonous inflammation frequently occurs in the glands 
of the mouth, the tonsils, the gums, the pulps of teeth, the 
lining membranes of the alveoli and antrum, and the tongue. 
Erysipelous inflammation in these parts is rare, but sometimes 
occurs in the mucous membrane, lining the gums, cheek, and 
palate. The submaxillary glands often take on inflammation 
from the effects of cold, and from the irritation produced by 
the presence of diseased roots in the alveoli of the lower jaw. 
The pain and difficulty of mastication, with the swelling of 
the gland, readily indicate the seat and character of the disor- 
der. Unless the inflammation be speedily subdued, and es- 
pecially if it be the consequence of diseased teeth, the gland 
readily suppurates, discharging a very fetid pus, either into 
the cavity of the mouth, or externally, under the jaw. When 
the opening takes place internally, the flow of pus into the 
mouth is very disagreeable, and the access to, and lodgment of, 
alimentary matters in the suppurating gland often keep up the 
inflammation until an external issue is secured. 

Removal of the diseased teeth generally causes a speedy 
cure. Of other remedial means we will discourse hereafter. 

Inflammation in these, as in all glandular structures, is apt 
to leave permanent indurations. 

Inflammation of the tonsils is of very common occurrence. 
Its most common exciting cause is cold. The inflammation 
is generally very acute, rendering deglutition, and even speech, 
very difficult, sometimes impossible. It is generally attended 
by severe constitutional symptoms. 

Tonsilitis or cynanche tonsillaris usually terminates by res- 
olution, but very often by suppuration. Permanent enlarge- 
ment and induration often ensue upon repeated attacks of the 
disease, and the swollen tonsils sometimes offer serious ob- 
struction to respiration. When this is the case, they may be 



68 NATURE OF DISEASE. 

removed with little difficulty, and without subsequent incon- 
venience. The palate and uvula are often the seats of inflam- 
mation. The latter is liable to erysipelas and oedema. These 
little organs are also subject to a chronic inflammation and 
slow suppuration, which gradually wastes them away. 

The parotid gland is rarely the seat of inflammation, ex- 
cept when it is the seat of a peculiar specific disorder, which is 
called cynanche parotidea or mumps. 

Inflammation of the lining membrane of the mouth is called 
stomatitis* 

Simple inflammation of this membrane is characterized by 
increased redness, swelling, and heat, but it rarely occurs ex- 
cept in connection with inflammation of the tonsils, larynx, 
or pharynx, or as the consequence of the irritation of denti- 
tion, or of acrid, or stimulating matters taken into the mouth 
for the purpose of allaying tooth-ache. In such cases it ter- 
minates by resolution. 

It is much more common to find this inflammation present- 
ing the appearance called "apthse." 

These are grayish or whitish specks, which look like ulcers, 
and are described as such by some authors, but which are ex- 
udations from the inflamed mucous membrane — when these fall 
off, the parts beneath are red and irritable, the cuticle being 
peeled off, and the cutis vera exposed. 

This disorder is generally supposed to indicate a correspond- 
ing disease of the surfaces of the digesting organs. It at- 
tends some forms of constitutional disorder, and constitutes a 
peculiar infantile disease, called thrush, of which we will have 
occasion to say more in connexion with dentition. 

The gums are very liable to inflammation, which is charac- 
terized by redness, swelling, soreness, and often by very severe 
aching pain. 

The most common cause of inflammation in these parts, is 
the irritation produced by dead teeth. We have already ob- 
served that dead parts are subject to the same laws which 
affect foreign bodies lodged in the flesh, and nature removes 

* Xrcyia— the mouth. 



NATURE OF DISEASE. 69 

them, or attempts their removal, by instituting inflammation 
and ulceration around them. In other words, it is provided in 
the fundamental laws of the animal economy, that dead parts 
shall irritate the surrounding parts and produce in them, those 
conditions which naturally lead to the expulsion of the offenders. 
But dead teeth are firmly set in the jaw, and withal, are of too 
dense structure to be readily softened and absorbed. It hap- 
pens, therefore, that they remain long after their partial or com- 
plete disorganization, to plague the soft parts with which they 
are connected. The gums under these circumstances are kept 
in a state of chronic inflammation, and are rendered exceed- 
ingly sensitive to the action of irritants. Cold, or any local 
application of an exciting kind, will, under these circumstances, 
occasion aggravation of the chronic affection, and cause acute 
inflammation, of a severe character, which is remarkably liable 
to end in abscess. 

The chronic inflammation is often attended with ulceration 
around the decayed tooth ; the soft parts being separated 
therefrom, in the vain attempt of nature to remove them. In 
consequence of the long continued and unavailing ulceration, 
an imperfect attempt is made by the vessels of the gums to 
supply the loss of parts by granulations. These are unhealthy, 
spongy, loose, and incapable of cicatrizing : in other words, 
they are fungus. These fungus growths bleed freely upon 
being touched with a brush, or hard body, and being constantly 
destroyed and renewed, add much to the fetor of the fluids of 
the mouth, which under these circumstances, is often intolera- 
ble. Inflammation of the pulp, and the lining membrane of 
its cavity is commonly, perhaps always, the consequence of 
caries of the bony structure of the tooth, and exposure of its 
sensitive internal parts to the action of external agents. It 
gives rise to violent pain, which only subsides to be renewed 
again, by contact with any hard body, or irritating substance. 
This inflammation may continue for a considerable length of 
time, passing through successive suppurations, and, ultimately, 
completely destroying the vessels and nerves of the pulp, and 
with them, the vitality of the tooth. 



70 NATURE OF DISEASE. 

Sometimes the matter formed within the tooth perforates the 
alveolus and the gum, and forms a fistulous* orifice into the 
mouth, through which putrid fluids are continually weeping. 
This is what is called alveolar abscess, and can only be reme- 
died by extraction of the tooth. 

The matter of alveolar abscess will sometimes be discovered 
at a great distance from its source. The following case which 
occurred in my practice, and which is related in Prof. Harris' 
Dental Surgery, as the most singular case of alveolar abscess 
which ever fell under his observation, affords a striking in- 
stance of this fact. 

The subject was a lady about thirty years old. She con- 
sulted me on account of a continual dripping of pus from be- 
hind the curtain of the palate, which she attributed to some 
disease of those parts, and which had annoyed' her for a year 
previous. 

Upon a close examination of her mouth and throat, I could 
discover no tumor or any indication of a deposit of matter 
except two protuberances, each nearly as large as a hazlenut, 
situated behind the two superior central incisores. Being 
strongly inclined to believe that the matter came from these 
abscesses, I requested the advice of Prof. Harris, who fully 
coincided in my suspicions. Upon our joint advice, the pa- 
tient submitted to lose these valuable teeth, and was rewarded 
by cure of the troublesome complaint which had caused her 
so much uneasiness. 

The maxillary sinus, or antrum, is covered by a membrane 
which nearly resembles the mucous covering of the mouth. 
This is frequently the seat of inflammation. From the pro- 
tected situation of this cavity, locked in on every side by bone, 
and covered by thick integuments, it is not apt to be affected 
by ordinary agents, acting from without, but the teeth of the 
upper jaw frequently send their roots into it, and thus affect it 
readily, when happening to become diseased, they are qual- 
ified to provoke disorder in neighboring parts. Even when 

• Fistula — a pipe, a canal whose sides and edges are hard and incapa- 
ble of adhesion. 



NATURE OF DISEASE. 71 

they do not penetrate the floor of the antrum, they are often 
separated from it by a partition so very thin as to afford no ade- 
quate protection to the antral membrane against the propa- 
gation of inflammation. 

When the membrane of the antrum is inflamed, it pours out 
a vitiated secretion, which accumulates for some time before 
it produces sufficient uneasiness to excite the attention of the 
patient. The pain of inflammation depends upon the degree 
of pressure to which the parts are subjected, and the peculiar 
structure of the antrum prevents much suffering from thi 
cause until the cavity is completely filled. 

Generally, however, some dull pain is felt in this region 
in the course of the inflammatory action, but the patient 
commonly refers it to the teeth. After a while, however, the 
distension of the walls of the cavity produce more serious suf- 
fering : matter escapes through the nose or mouth, and a hard 
bony tumor indicates the projection of the antral walls. 

The fluid thus accumulated is usually not pus, but vitiated 
mucous. The disease has been very improperly called dropsy* 
of the antrum, for the contents are by no means serous. 

The discharged matter, having been long retained, is gen- 
erally very offensive. 

Ulceration may also take place in the membrane of the an- 
trum, and pus of a very fetid quality be exuded through the 
nose, and when an opening exists, through the mouth. This 
condition forms one of those exceedingly distressing, and 
often incurable cases of disgustingly fetid breath, which are 
called ozena. 

Sometimes, when the disease is permitted to proceed with- 
out proper remedial means being used, the walls continue to 
swell ; the bones soften, the tumor opens, and a fetid dis- 
charge flows through the aperture over the cheek. 

hiflammatory Fever. 

Fever,f or pyrexia,! is a morbidly increased activity of the 
heart and arteries, the proximate cause of which is little under- 
* I25wp — water, f Ferbeo — I burn. J m>p— fire. 



72 NATURE OF DISEASE. 

stood, but which is attended with general disturbance of func- 
tion. 

Merely increased action of the heart and arteries is not fever, 
for such excitement may be purely physiological and attended 
with no functional distress. Violent exercise and mental emo- 
tions will frequently cause the vascular system to work with 
vastly greater energy than usual, while the individual who is 
the subject of the accelerated circulation will not be at all mor- 
bidly affected. 

But in fever, the increased vascular action is the effect of 
disturbing morbid causes. Often, perhaps always, the blood 
itself has undergone change, and the vital fluid thus altered, 
being supplied to all the organs, begets universal disorder of 
function. 

Fever is either idiopathic,* or symptomatic. 

By idiopathic fever, we mean that form of it which ap- 
pears to us to represent the primary, or original disorder,! being 
the first observable affect of the morbific cause. Such fevers 
are not, so far as we know, preceded by a local disease, whose 
existence and intensity are represented by the vascular action. 
We cannot, in the present state of our knowledge, go behind 
the fever to find out its immediate cause, structural change or 
functional error. 

Symptomatic, or secondary fevers, or as they are often called, 
from the nature of the conditions they most frequently repre- 
sent, inflammatory fevers, are merely consequent upon local 
disease, having no independent existence, but rising and 
fall-ing with the flow and ebb of the disorder they repre- 
sent. 

These two conditions, though called by the common name, 
fever, are entirely distinct and different in their cause, nature, 
progress, and treatment, and are only allied together, by the 
fact, that each of them is attended with morbidly increased 
vascular action. 

Neither is symptomatic fever a unit; for when it repre- 
sents inflammation, it differs essentially from the vascular con- 

*tft,o$, proper, or peculiar. | Ila0o$, disease. 



NATURE OF DISEASE. 73 

dition, which is consequent upon another state, which is 
called irritation, and which seems to consist in a merely aug- 
mented sensibility of a part, and the distress occasioned 
through it. 

The sensible peculiarity of inflammatory fever consists in 
two elements ; the hardness of the pulse, and the buffy coat of 
the blood. 

In all kinds of fever the pulse may be quick and frequent, 
but as a general rule, to which the exceptions are very few, we 
may regard hardness as indicative of inflammation. 

When blood is drawn in a full stream from the veins of a 
patient laboring under inflammatory fever, it will, upon coagu- 
lation, present a fibrinous surface of a yellowish hue, the 
abundance of which, will, to a great extent, mark the inten- 
sity of the inflammation it represents. Very often, too, it will 
assume a peculiar form, being depressed in the center, and 
raised at the edges ; an appearance which is called "cupped," 
though the resemblance is nearer to a saucer. 

It generally happens that this appearance is more manifest 
after the disease has progressed several days than in its incip- 
iency ; and is often more observable upon a second, than a 
first bleeding, a fact which has led to the very erroneous 
opinion, that the abstraction of blood favored this kind of 
alteration. The best mode of observing this buffy coat is to 
catch the current of blood in a deep narrow vessel, such as a 
wine or jelly glass. 

Inflammation of fibrous tissues produces more of the buffy 
coat than is found consequent upon the same disease in other 
structures. 

It must be remarked, however, that the buffy coat is found 
upon healthy blood drawn from pregnant women. It is occa- 
sionally, but rarely met with when the circulation is morbidly 
active from other causes than inflammation. Mercurialization 
also imparts this appearance to the blood.* 

* The author had one patient laboring under slight enlargement of the 
heart, whose blood always presented a buffy coat. In a somewhat exten- 
sive practice of nearly fifteen years he has never found the blood of an 
inflammatory patient without it. 
7 



74 TREATMENT OF INFLAMMATION. 



Treatment of Inflammation. 



In all cases of inflammation it is desirable to bring about 
the disappearance of the disease without any disorganization of 
structure. In other words, to accomplish cure by resolution. 
When this cannot be effected it is important to lessen suppu- 
ration, and if possible to prevent, or, at least, limit mortifica- 
tion. 

The first step towards accomplishing the cure of inflamma- 
tion is to remove, if we can, the cause which produces it. 
This will often render further treatment very simple and easy, 
or altogether unnecessary. Where the gums, or lining mem- 
brane of the antrum are inflamed through the irritation caused 
by diseased or dead teeth, no treatment short of their removal 
will do any good : and this will generally be a sufficient aid to 
nature. Even when the soft parts are suppurating, they will 
speedily heal after the irritant has been removed. 

The treatment of inflammation proper, consists in general 
and local means. With the exception of a few employed to 
relieve chronic inflamed conditions, these remedial measures 
are comprised under the general name antiphlogistic * and are 
all intended to lessen the vascular action, of the general or 
local circulation. 

Antiphlogistic treatment is negative or positive. The neg: 
ative consists in withholding every local application likely to 
excite the vessels, or irritate the morbidly sensitive nerves of 
the part : and preventing the taking of such drinks or aliment 
as would tend to sustain the morbidly active circulation. In 
hort, the withdrawing as far as possible of all local and gen- 
eral excitants. 

The positive treatment consists in the use of means which 
lessen vascular action and diminish nervous sensibility. The 
general remedies are blood-letting, purgatives, diaphoretics, 

* Anti, against — Phlogiston, the old name for the cause of heat. 



TREATMENT OF INFLAMMATION. 75 

and low diet; among the local are blood-letting, from the 
affected part, or its immediate vicinity ; cooling, emollient, 
sedative, and astringent applications, and counter-irritants. 

When pus has been formed in a cavity, it is often necessary 
to evacuate it by an artificial opening: sometimes, even after 
the tumor has opened spontaneously, a counter-opening is ne- 
cessary. 



Treatment of Inflammation and Abscess of the parts composing 
the Mouth. 

It is rare that inflammation of these structures require general 
treatment. Sometimes, however, they are sufficiently serious 
to occasion inflammatory fever, and call for decided constitu- 
tional remedies. When such is the case, the patient should 
be bled from the arm until a decided impression shall have 
been made upon the circulation, and the operation must be re- 
peated, until the desired effect be accomplished. If the bowels 
of the patient be constipated, saline cathartics should be em- 
ployed. Nauseating remedies, such as tartar emetic, will also 
be found useful in lessening the general inflammatory action 
and withdrawing the nervous sensibility from the affected part. 

In most cases, however, the dental surgeon will only need 
to employ local remedies. 

We have already said that when the inflammation is conse- 
quent upon the presence of diseased teeth, or parts of teeth, 
they must be removed. This being done, the inflammatory 
action will commonly subside and speedily disappear. The 
teeth are liable to a peculiar calcareous deposit, called tartar,^ 
or salivary calculus, which adheres with great tenacity to 

X Tartar, or salivary calculus, is composed, according to Berzelius, of 
Phos. lime and magnes. 79.00 

Salivary mucus and salavine, 13.50 

Animal matter, 7.50 

100.00 



76 TREATMENT OF INFLAMMATION. 

them, and insinuating itself under the edges of the gums, 
detaches them from the teeth, and acting as a perpetual irri- 
tant, inflames, and often ulcerates them. 

This substance is deposited from the saliva under certain 
conditions of that fluid, and is most liberally deposited upon 
the teeth nearest to the salivary ducts and upon those of the 
lower jaw. When it contains a larger proportion of earthy 
salts, it is hard, and brittle; when the animal matter is in ex- 
cess, it is soft and moist. Under which ever of these forms it 
appears, its removal is indispensable to the successful treat- 
ment of the disease of the gums which it causes. Sometimes 
this can be effected by the brush alone ; often the hard mineral 
substance requires to be broken up and elevated by an instru- 
ment of steel. When once removed, its subsequent accumu- 
lation must be prevented by persevering use of water and the 
brush. 

It often happens that the gums will be inflamed through the 
agency of teeth, the disease of which is not sufficiently serious 
to authorize their removal ; again, inflammation may occur in 
the gums from causes independent of the teeth, as from cold, 
irritating applications, bruises, &c. 

In order to prevent acute inflammation of the gums from 
passing rapidly to suppuration, it is necessary to use free local 
depletion. This may be done by scarification, or by leeching. 

Scarification is nothing more than slightly incising the gum 
and causing its superficial vessels to bleed. 

It is a remedy of doubtful utility, and often does more harm 
than good. 

It is obvious, that, any wound inflicted upon an inflamed 
part must increase the inflammation to a certain extent, and 
unless the quantity of blood taken away be more than sufficient 
to counterbalance the additional evil inflicted, the patient will 
lose by the operation. Scarification produces copious bleed- 
ing for the instant, but the clean superficial wound is soon 
closed by coagulum, and lymph, and the oozing of blood con- 
tinues but a short time. 



TREATMENT OF INFLAMMATION. 77 

When the gums present the condition called fungus, scarifica- 
tion will cause much freer bleeding, owing to the increased 
vascularity of the part. Under such circumstances it is an im- 
portant means of cure. 

Leeching is a far more effectual process. It is true that 
wounds are made by the leeches deeper and more irritating than 
those inflicted by the lancet, but the flow of blood continues very 
much longer and the quantity discharged is far greater. 

Two or three leeches placed upon a gum will often cause a 
bleeding which will continue for several hours, and will cure 
severe inflammation in almost as brief a space of time. 

In order to be effectual, leeching should be employed in the 
early stage of inflammation. If delayed until matter has begun 
to form, no benefit can be expected, except, perhaps, in the les- 
sening of the quantity of pus. 

Other local applications are of little or no use in the treatment 
of acute inflammation of the gums. Their position prevents the 
continuance of any fluid upon their substance. Cold water, how- 
ever, may be used by repeatedly filling the mouth with it. This 
remedy is serviceable only in slight inflammations. All stimula- 
ting applications used to irritate the surrounding parts and thus 
alter and divide sensation so as to relieve pain, ultimately aggra- 
vate the disease, It is erroneously supposed that the increased 
flow of secretions which is occasioned by the irritation, must 
relieve the vessels and abate the inflammation, for the very irrita- 
tion attracts to these parts a larger supply of blood than usual, 
and augments secretion only by increasing arterial activity * 

Where the inflammation is excessive, leeching and blistering 
behind the ears or under the jaws may be resorted to. 

As great and long continued suffering frequently attends this 
disease, full opiates at night may be given with great advantage; 
securing at once temporary relief and grateful repose, and aiding 
materially the efforts of nature to remove the inflammation. 

Inflammation from mechanical violence must be treated upon 
the same principles. 

*Ubi irritatio, ibi fluxus — where there is irritation, to that place will be 
the flow, is a well known medical adage. The law applies to the nervous 
as well as the vascular system. 
8 



78 TREATMENT OP INFLAMMATION. 

The gums are liable to inflammation of a specific character. 
When mercurial preparations have been used to a certain extent 
differing much in different individuals, a constitutional impression 
is obtained, which announces itself by a peculiar tenderness and 
inflammation of the gums and an increased secretion of mucus 
and glandular fluids into the mouth. This is called salivation 
or ptyalism * 

The first symptoms of this mercurialization are observed in an 
increased tenderness and some swelling of the gums which 
exhibit a pale rose color, except at the edges surrounding the 
teeth, when they are of a deep red. The soreness and swelling 
now rapidly increase, the discharge of mucus and saliva becomes 
excessive, and is accompanied by a very peculiar and disagreea- 
ble odour; a metallic or coppery taste is constantly present in the 
mouth, and the tongue and salivary glands are inflamed and swollen. 

Such is moderate salivation, but it sometimes happens that 
from excessive dosing with mercury or from peculiar suscepti- 
bility of the patient, all the symptoms above enumerated are 
greatly aggravated. The gums are very much swollen and cov- 
ered with ulcers; the enormous tumor of the tongue pushes beyond 
the lips and hangs out of the mouth, preventing the closure of the 
jaws ; the flow of fluids is prodigious, the patient wastes exces- 
sively gangrene of the mucus membrane of the mouth and gums, 
and extensive sloughing of the soft parts and bones sometimes 
occur; the teeth are loosened and sometimes drop from their 
sockets and occasionally the patient expires from exhaustion. 

A very frequent consequence of extensive mercurial salivation 
and the attendant ulceration and sloughing, is contraction of the 
mucus membrane in the neighborhood of the anterior arches of 
the palate, whereby the patient is prevented from opening the 
mouth, except to a very slight extent. In one case this condi- 
tion resulted from salivation produced by a few grains of blue 
pill. The patient was unable to open the mouth wider than half 
an inch. Surgical aid could give only temporary relief. In an- 
other instance, a child four years old, the patient when seen 
several years afterwards, was obliged to suck food through the 
spaces left between the jaws by the loss of the alveolar process.f 

* Ptyalism — salivation from tt»u — I spit. 
fPareira's Elements of Materia Medica and Therap. 



TREATMENT OF INFLAMMATION. 79 

It sometimes happens as a consequence of salivation, that ad- 
hesions form between the mucus membrane of the lips and cheek 
and that of the gums; very much deforming the face and lessen- 
ing the usefulness of the mouth. 

A great variety of remedies have been suggested and employed 
for the relief of excessive salivation, but there is no specific 
means of relief, no local applications of an irritating character 
can be borne, and no astringent but of the mildest quality can be 
used. Besides demulcent lotions and some very mild astringents, 
such as table tea, we have no topical applications to recommend. 

The only rational treatment is to abate the inflammation by the 
use of antiphlogistics, to such extent as the strength of the patient 
will permit. Leeches under the jaws procure the greatest relief 
and blisters to the throat, and opiates are useful accessories.* 

A form of disease very nearly resembling salivation, occurs 
occasionally in children, and sometimes it is said even in adults. 
It is ulceration of the inside of the cheek, causing gangrene and 
a copious secretion of fetid saliva. It is called Cancrum oris. 

This disease is not properly inflammatory, being rather a con- 
sequence of debility, but lest we should not have an opportunity 
to describe it hereafter, we will do so now. 

Cancrum oris is a foul fetid ulcer, beginning upon the inside 
of the cheek and rapidly sloughing through it until it opens upon, 
the outside. The gums and alveoli are often seriously involved ; 
the teeth become carious and loose, and drop out; abscesses form 
in different parts of the mouth and make openings for them- 
selves in different directions. The progress of the disease is at- 
tended by a copious discharge of fetid saliva and mucus. Ex- 
foliations of bone are not unfrequent and extensive sloughing 
sometimes occurs. 

The disease generally occurs in ill-fed children, crowded in a 
hospital or living in low swampy situations. The remedies must 
be tonic and invigorating. The principal, are fresh air and 
nutritious diet. The best local applications are diluted mineral 
acids; burnt alum, sul. zinc, tinct. of myrrh, &c. 

*It is important to remark that salivation, however severe, does not neces- 
sarily prove the previous administration of mercury. For some curious 
observations on this subject, see Pareira's Elements of Mat. Med. and 
Therap. 709. 



80 TREATMENT OF INFLAMMATION. 

The disease is exceedingly rare in our country. 

Syphilis or the venereal disease, often produces ulcerations 
of the throat, which are described in the many books upon that 
particular subject and require no particular notice here. 

It is proper, however, for Dental-Surgeons to know that a 
peculiar and destructive ulceration of the gums which will defy 
all but specific remedies, sometimes, through very rarely, attends 
Syphilis. As it is impossible to describe the peculiar appear- 
ance of this ulceration by words only, so as to enable the prac- 
titioner to detect it upon sight, we refer the reader to an excel- 
lent delineation of it in Messrs. Carey & Hart's Edition of 
Rayer's Plates, PI. xxix., Fig. 15. 

Chronic inflammation of the gums may depend upon any of 
the causes mentioned as productive of acute inflammation. It 
tends rather to ulceration than abscess. 

If there be no specific cause, after removal of any dead teeth, 
&c, the gums require the aid of astringent and somewhat stimu- 
lating lotions, such as port wine and water, weak brandy and 
water, myrrh, infusion of Peruvian bark, &c. 

There is a common form of disease which is usually called 
scurvy or scorbutus of the gums. This designation, however, is 
very improper; for scurvy is a constitutional affection depending 
upon long privation of fresh and acescent food, aided by the 
influence of cold, dampness, &c. It is a disease peculiar to ships 
and prisons, and the affection of the gums which attends it, is but 
one among many symptoms of the disorder. It is well, therefore, 
to abandon this term, scurvy, as applied to the local disease of the 
gums in question, and following the example of Professor Harris, 
we will consider it as an idiopathic inflammation of the gums, 
attended by sponginess of structure, recession of their margins 
and frequently, destruction of the alveolar processes. 

When affected by this disease, the gums present a swollen ap- 
pearance. Their color is dark-red or purple ; they feel elastic 
under the finger, and when pressed, pus oozes out between the 
teeth and the margins of the gums, which are thickened and 
detached. The proper tissue of the gums having become to a 
certain extent fungus, bleeds upon the slightest touch and is very 
sensitive. 



CARIES. 81 

The disease progresses with more or less rapidity according 
to the constitutional health of the patient, and the capability of 
resistance natural to the organs attacked. Sometimes it is con- 
fined to a small portion of the gum, at others, it involves the 
periostea of the fangs and the alveoli, and presents a mass of 
complicated disorder and devastation. A deposition of bony 
matter sometimes takes place in the bottom of the sockets and 
the teeth are loosened and drop out. 

The treatment of this disease does not differ from that of the 
ordinary inflammatory conditions previously described. Indeed 
it is not specifically different. 

All irritating bodies such as decayed teeth and roots must be 
removed : irregularities of denture corrected : tartar also taken 
away : the gums depleted : and after active inflammation has sub- 
sided, astringent lotions may be used by way of correcting the 
habitual looseness of texture.* 

Caries.^ 

This term has different meanings when applied to the bones at 
large and to the teeth. We will first consider the disease of the 
bones so called. 

Caries in the bones is a disease analogous to ulceration of the 
soft parts, and is very different from necrosis or mortification of 
these parts. 

The bones are vital organs, supplied with arteries, nerves, 
veins, absorbents and cellular tissue. Like soft parts they 
grow and waste, undergo disease and accomplish reparation. 

The denser the texture of a bone the less liable it is to be 
attacked by caries, and for this reason the bones of children are 
more susceptible of it than those of adults. 

In caries the bone undergoes a change by which its texture is 
softened and broken down ; fungus flesh which bleeds very 
readily grows up in the interstices formed upon the surface of 

• For a more extended description of this disease and its treatment, than 
is compatible with the scope of this work, see Dr. Harris' Dental Surgery, 
a work which we will take for granted is in the hands of every scientific 
dentist and every student of dentistry. 

■{• Kei£Eiv — to abrade. 

8* 



82 MORTIFICATION OR GANGRENE. 

the diseased bone ; fetid dark-colored sanies finds its way to the 
surface through a sinuous channel, and a communication is thus 
formed between the diseased bone and the external parts. 

Caries may nevertheless progress for a long time without the 
formation of an ulcer and discharge of matter; and these results 
depend more often on necrosis than on caries. 

The treatment of caries consists in the removal of the diseased 
part by surgical means, and, as is often necessary, the applica- 
tion of the actual cautery upon the new surface. The latter 
means is not absolutely indispensable, the former probably is, 
unless, as sometimes happens, the separation of the unsound parts 
may be accomplished by the unaided efforts of nature. 

Caries of the teeth, is a chemical erosion of those organs by the 
action of the fluids of the mouth, and the accidental matters dis- 
solved in them, upon the salts of which the tooth is mainly 
composed. 

It is yet a mooted question whether the teeth are ever subject 
to true caries, such as affects other bony structures. I have 
already remarked that this disease is not apt to occur in the 
denser osseous structures, and the close texture of the teeth 
renders them particularly unlikely to be thus effected. Yet it 
might be too much to say that they are never subject to the active 
disorganizing process in question. It is certain, however, that 
caries of the teeth, as commonly met with, is a mere chemical 
erosion resulting from the action of acids upon the earthy salts 
which principally compose them. A human tooth, inserted as a 
substitute in another mouth will undergo this change as readily as 
a natural tooth will do; showing that in this form of destruction 
the organs assailed are passive. 

Mortification or Gangrene. 

These two words are commonly used synonymously to express 
absolute death of apart, but by some writers the term gangrene 
is restricted to that condition which immediately precedes death, 
and Sphacelus* applied to the latter condition, while mortifica- 
tion is a general term covering both conditions. 

According to this use of the terms, gangrene represents the 

* Isxxtt v — to destroy. 



MORTIFICATION OR GANGRENE. 83 

condition in which there is a sudden diminution of pain if it has 
previously existed ;a livid discoloration and subsequent yellowish 
or greenish hue of the part; a detachment of the cuticle with 
effusion of a turbid fluid beneath it, and a softening and crepita- 
tion of the part. 

When the part has become cold, insensible, black, motionless, 
without circulation, motion and life, the condition is called 
sphacelus. The state of bone analogous to this is called necrosis 
and the dead part when detached a sequestrum.* 

Mortification may result from any cause which prevents the 
nutrition of a part. Inflammation may so interrupt the circu- 
lation as to cut off the supply of blood, or the state of the patients 
digestion may not afford a supply of nutrient fluid sufficient for 
those parts, which are least vascular or most distant from the 
heart, and certain obscure changes may take place in a part 
which may cause it to mortify without the precedence of appre- 
ciated disease. 

When mortification is consequent upon inflammation, the 
quantity of fluids in the part causes a humid state of the sphacelus ; 
where death has taken place from deficiency of blood the morti- 
fied parts are dry and shrivelled. These opposite conditions 
have given occasion to the distinction so generally recognized 
between moist and dry gangrene. This distinction, however, is 
not so absolute as to be without exception, yet it is correct to a 
considerable extent. 

Different parts assume different appearances when gangrenous, 
" Tendons, muscles, nerve and cellular substance, look like dirty 
shreds of wet tow, the skin sometimes looks as if it had been 
destroyed by caustic or the cautery." The arches of the mucus 
membrane are often of a grayish or whitish color. Quesnay 
states that in one case he saw, the gangrened parts exhibited a 
remarkable transparency. The black color cannot therefore be 
considered as characteristic of gangrene. It may exist indepen- 
dently of mortification, and the latter may exist independently of 
the other. The principal characteristics of gangrene are, 1st. 
Complete disorganization of the gangrenous parts, in which the 
elementary tissue can no longer be distinguished. 2d. Softness 

• Sequestro — I separate. 



84 MORTIFICATION OR GANGRENE. 

and flaccid ity. 3d. The fetid and characteristic odour which it 
enhales. 4th. The sanies, ichor and fetid gas which escape from 
it. In that variety of gangrene, termed dry, the part presents a 
black color, a hardness sometimes like that of wood, and always 
a complete disorganization of the tissue.* 

The treatment of gangrenous parts must be directed to the 
limitation of the mortification, and to the removal of the slough. 
When a part has become dead, it seems to act as a depressing 
or devitalizing agent upon the surrounding parts, and even upon 
the general system. If the gangrene take place in one of the 
viscera, the patient generally sinks rapidly and soon expires. 
Immediately upon the gangrenous change, the pulse becomes soft, 
weak and frequent, the skin cold, and the nervous system seems 
to labor under a silent, but deadly influence not to be resisted. 

It is difficult to account for this sudden and extraordinary 
result. It is generally supposed that the fluids of the gangrenous 
part, being absorbed, prove poisonous to life ; but if this were 
the case, similar effects would result from the much more 
extensive mortifications which frequently occur in the skin, 
muscles and bones, without those serious constitutional results. 
The effect must rather be attributed to the powerful sympathy 
which exists between the viscera and the nerves of organic life. 

Where nature makes an effort to check the spread of gangrene, 
which, except in the instances referred to, she almost always 
does, a red line of inflammation is first drawn around the affected 
part. Ulceration soon takes place along this line, and a suppu- 
rating furrow separates the dead from the living parts. A similar 
process goes on beneath, and advancing granulations gradually 
push off' the gangrenous slough, and supply its place with sound 
flesh. Inflammation and ulceration, therefore, are the means 
employed for the removal of dead parts, and for limiting the pro- 
gress of devastation. 

In order to effect this, it is necessary that the vitality of the 
adjoining parts be sufficient to produce healthy inflammation, 
support the suppuration and sustain vigorous granulations. It is 
also necessary, that the inflammation in the adjoining parts be 
Dot so great as seriously to impede the circulation in them. 

* Chomel, Elements of Gen. Path. 



MORTIFICATION OR GANGRENE. 85 

The surgeon takes his suggestion of remedial treatment from 
these necessary conditions. If the parts adjacent to the gangrene 
be cold and livid, and if they show no disposition to throw out 
the inflammatory cordon sanitaire, he sees the necessity of stim- 
ulating applications to rouse the torpid energies of the threatened 
parts. Cantharides, turpentine, or other remedies of thi3 
powerful class will then be put in requisition ; and should the 
parts under the slough be equally torpid, he will cut through the 
mortified covering and apply his excitants to the flesh beneath. 

Sometimes, though not often, he will find it better to anticipate 
the slow process of nature, and at once remove the gangrene by 
his knife. The latter process is fraught with this difficulty, that 
when the surrounding parts are feeble and disposed to gangrene, 
the use of the knife imparts to them no strength while it neces- 
sarily inflicts injury. The result often is the appearance of 
the disease in the remaining parts. 

When the surrounding parts manifiest more excitement than is 
compatible with their security, depleting and sedative treatment 
must be instituted. As a general rule, however, this will rarely 
be required, for the vicinity of gangrene is generally abundantly 
sedative to the surrounding parts. 

Necrosis, or mortification of bone may take place from similar 
causes to those, which produce gangrene of the soft parts. As 
the bones possess less vitality, they are less capable of resisting 
disease, and therefore are more prone to die from injuries and 
internal causes than other parts. That they are not more fre- 
quently necrosed than they are, depend upon their protection 
from external violence by the soft parts, and the fact, that their 
limited vitality and simple functions involve less tendency to 
disease than is connected with the more exquisite organization 
and complicated functions of other organs. 

Necrosed bone is thrown off by a process very analogous to that 
which is instituted for the separation of sphacelus. Where the 
mortification is superficial, it is removed by exfoliation: when it 
is deeper, a persevering effort is made by the surrounding bone 
and soft parts, to detach and expel it in the form of splinters or 
even of large masses, called sequestra. 



86 MORTIFICATION OR GANGRENE. 

Owing to the density of bone and its deep seated position, this 
is generally a very slow process, requiring months and years for 
its accomplishment, and often failing altogether. For after long 
continued fruitless efforts to get rid of the dead part, nature 
frequently attempts to supply the deficiency caused by its loss and 
forms new bone around it, leaving orifices in this bony case, 
through which the matter may find a vent. When this arrange- 
ment has been made, the sequestrum cannot be expelled by 
natural efforts, except in a fluid or very comminuted state. It is, 
therefore, generally necessary for the surgeon to cut down to the 
diseased bone and liberate the sequestrum. 

Occasionally however, nature, though unassisted, will accom- 
plish the expulsion of very large sequestra. In one recorded 
case, a piece of bone seven inches long, was thus expelled: such 
cases, however, are very rare. 

The presence of necrosis or caries, may be ascertained very 
satisfactorily after the formation of the external ulcer. Some- 
times the canal will be so straight as to permit a probe to reach 
the diseased part, and when this is not the case the presence of 
an obstinate ulcer, evacuating dark-colored and fetid sanies, 
will generally be sufficient evidence of diseased bone. 

It is rarely possible to distinguish necrosis from caries, until 
the sequestrum has become so fully detached as to be moveable. 
The cure of necrosis as of caries, if procured by art, depends 
upon the removal of the part so diseased. In necrosis, the parts 
surrounding the sequestrum are generally in such a state as to 
return to health after its removal. In caries, the surface of the 
parts exposed by the operation, often require the application of 
the cautery as before stated. 

We have already mentioned, that what is called caries of the 
teeth, differs very essentially from the disease of the bones, 
which bears the same name. 

Caries of the bones, as we have seen, is a diseased vital action, 
in which the vessels, &c. are active: caries of the teeth is simply 
a chemical erosion which may be imitated upon teeth separated 
from the mouth, and affects dead teeth as readily as living ones. 
Caries of the teeth always begins upon their outer surface, 
and does not appear to be in any manner dependent upon disease, 



MORTIFICATION OR GANGRENE. 87 

except so far as it may be favored by an unhealthy structure of 
the teeth, and a morbid condition of the fluids of the mouth. 

In short, caries of the bones is a vital, that of the teeth, a 
chemical process. 

By instituting a comparison between caries of the teeth and 
that of other bone, it will at once be perceived, that there is not 
the slightest analogy between the disease as it occurs in the one 
and manifests itself in the other. In the former, it consists simply 
in a decomposition of the earthy basis of the organs, whereas, in 
the latter it is analagous to ulceration in soft parts, and constantly 
discharges a fetid sanies, and frequently throws out granulations 
of fungus flesh. These are phenomena which dental caries never 
exhibits, and they establish a wide difference between it and the 
disease as occurring in other osseous structures of the body."* 

The treatment of caries belongs to Surgical Dentistry, and to 
works on that subject, and particularly to the excellent treatise 
by Prof. Harris, we refer the reader. 

Necrosis may take place in the teeth as in other bones, and 
from a similar cause, the cessation of circulation in them. 

This may be effected by violence. The teeth, especially the 
anterior ones are very much exposed to be injured by blows or 
falls, and it sometimes happens, that a shock thus inflicted is 
sufficient to break up the vascular connections of the organ 
without displacing it from its socket. 

More commonly here as in other bones, the necrosis takes 
place as a result of inflammation ; the pulp having been destroyed 
by this process. 

When a portion of bone dies, the surrounding bone sets up a 
process of removal and reparation. Nothing of this kind occurs in 
the teeth; partly because the evil is generally shed over the 
whole organ at once, and partly because its low vitality does not 
permit of such effects. 

After necrosis has taken place, the tooth having become a 
foreign body produces the usual effect of such causes upon the 
surrounding soft parts. The gums inflame, ulcerate and detach 
themselves from the tooth; but not being assisted by similar 

* Harris' Dental Surgery, which see, tor a thorough examination and 
exposition of this subject. 



88 MORTIFICATION OR GANGRENE. 

processes in the bone they are unable to remove the evil. Chro- 
nic disease is, therefore, commonly the consequence. 

Necrosed teeth lose their color and become dark-brown, 
bluish or dingy, sometimes when presenting this appearance, 
their vitality is not completely destroyed, and therefore, they 
may remain in the mouth for years without provoking the disease 
of the soft parts which would require the removal of the necrosed 



CHAPTER VII. 

ULCERS. 

An ulcer is a running sore : or, in medical language, a solution 
of continuity in a soft part, with a secreting surface. 

Ulcers present a variety of appearances, depend upon very 
different causes, and exhibit dissimilar conditions of the parts 
implicated in them. 

A great many attempts have been made to classify ulcers. 
Some authors have endeavored to arrange them by their apparent 
phenomena, others by their pathological conditions, and others by 
the modes of cure to which they severally yield, while some 
have seized upon accidental modifying circumstances as a reason 
for multiplying subdivisions already too numerous. 

It is impossible to systematize in pathological science, so as 
to provide for all the numberless modifications which may be 
produced in disease by the causes which influence vital action. 
We must content ourselves with such an arrangement as will 
enable us lucidly to express what we know of the subject. Once 
more we remind our readers that medical definitions are not 
philosophically complete and accurate. 

An important distinction between ulcers is found in the fact 
that some of them are the result of local injury or disease, and 
not in any manner dependent for their existence upon constitu- 
tional vice, while with regard to others the converse is the case ; 
the local sore being only a consequence of constitutional disorder. 
As the treatment must differ essentially in these different cases, it 
is very important to be able to distinguish the one class of ulcers 
from the other. 

Yet even this distinction, apparently so obvious and proper, is 
not without difficulty, for local ulcers sometimes involve the 
general health, and are instrumental in setting up diseased consti- 
tutional action, in which they themselves participate, and, on the 
9 



90 ULCERS. 

other hand, ulcers primarily induced by constitutional causes, 
may continue after the vice of the general system has been 
corrected. 

The causes of ulcers are various, but can generally be reduced 
to the following classes: 

1. Predisposing causes. All those conditions of the system, or 
of any of its parts, which debilitate structures or so alter their 
vital action as to impede recuperative processes. Fever, scrofula, 
syphilis, and scurvy, are examples of this kind. 

2. Exciting or immediate or local causes: such as wounds, 
bruises, abscess, suppuration, gangrene, abrasion of the skin from 
any cause. 

3. From the combination of these causes. A slight scratch or 
excoriation that in a sound constitution would heal without any 
trouble, in a habit tainted with disorders as above mentioned, will 
frequently produce a very disagreeable and tedious ulcer.* 

The prognosis of ulcers, must, of course, depend upon the 
results of a full consideration of the causes and conditions in- 
volved in any particular case. The constitution of the patient, 
his age and habits, the situation and duration of the sore and its 
peculiar condition of sensibility, &c, must all have due considera- 
tion in forming a prognosis. 

It is always proper to attempt the cure of ulcers, except 
such as are of a malignant character, known to be incurable 
through any means yet known to us. 

After ulcers have become chronic, it is sometimes dangerous to 
heal them until we shall have provided an artificial drain, by 
seton or issue. The system having once become habituated to 
the discharge of ever so small a quantity of matter, often sutlers 
severely with a kind of plethora if the discharge be suddenly 
stopped. 

The simplest, most practical, and most rational of all the 
classifications of ulcers we have seen, is that adopted long since 
by Mr. Benjamin Bell, and generally superseded by more compli- 
cated arrangements, which beget confusion in the mind of the 
student, and are, after all, not more precise and accurate than the 
one for which we have professed our preference. 

* Benjamin Bell on Ulcers. 



ULCERS. 

Mr. Benjamin Bell classifies ulcers as follows : 

LOCAL AND CONSTITUTIONAL. 

1. The simple purulent, 1. The venereal, 

2. The simple vitiated, 2. The scorbutic, 

3. The fungus, 3. The scrofulous. 

4. The sinuous, 

5. The callous, 

6. The carious, 

7. The cancerous, 

8. The cutaneous. 
It is not our purpose to describe in detail the appearance, 

nature, and treatment of each of the kinds of sore above enu- 
merated ; but we will confine ourselves to the consideration of 
such as may occur in the mouth, and thus fall under the notice 
and care of the Dental Surgeon. 

The simple purulent ulcer is the simplest form of sore. It is 
alwavs a local affection ; it is attended with little pain, and but 
slight inflammation, and furnishes healthy pus and firm granulations. 

A sore of this description needs little or no aid from art, but it 
is important that the student should be well acquainted with its 
appearance, because other ulcers, of a less simple and kindly 
character, must be brought to this condition before ultimate cure. 

The simple purulent ulcer is always produced by some local 
injury, as wounds, burns, &c, happening to persons of sound 
general health. 

In this kind of sores the pus is white and thick; the granula- 
tions small, firm, florid, and pointed. As soon as they have 
reached the level of the surrounding parts, those next the edges 
become smooth, and are covered by a whitish pellicle, or film, 
which afterwards hardens, advances, and forms the permanent 
covering of the parts previously ulcerated. This white, smooth 
margin, lost in the surrounding skin or mucous membrane, is one 
of the surest characteristics of this kind of sore, but it is not 
infallible; other qualities must be duly considered, before a con- 
clusion is formed. 

Such ulcers require no treatment except to be kept clean, and 
protected from any interference with the natural process which is 
Listening to cure. 



92 ULCERS. 

A little dry lint will accomplish all that can be done by dress- 
ings. A simple purulent ulcer may very readily be converted 
into an angry and obstinate sore by improper local applications, 
or the occurrence of general constitutional disorder. 

We may remark here that no sores are cured by applications of 
any kind ; nature only can provide the means by which these 
breaches can be healed. Nothing is more incorrect or dangerous 
than the idea that certain dressings have a specific or magical 
virtue, by which they close wounds, and cicatrize ulcers. The 
Surgeon may aid nature — he cannot supply her place: and his 
business is, generally, so far as the cure of ulcers is concerned, 
to aid her in her efforts to bring any particular sore into that 
condition " which natural means will suffice to relieve." 

Simple vitiated ulcer. When, from any of the causes we have 
mentioned, nature fails to produce such a condition of ulcer as 
we have described, in any part which has been wounded, or 
when, from improper dressings, motion, and fatigue of the dis- 
eased part, or constitutional causes, the progress towards cure is 
arrested, the discharge from a sore may present one of the fol- 
lowing appearances : 

1st. It may be a thin, limpid, sometimes greenish discharge, 
termed sanies. 

2d. A somewhat red-colored, thin, and generally very acrid 
matter, termed ichor. 

3d. A more viscid, glutinous kind of matter, called sordes* 

While discharging matter of a kind like any of these, an ulcer 
will not heal. The granulations become dark and waste away ; 
the matter, especially that called ichor, is very acrid and renders 
the sore very irritable and painful. It frequently excoriates the 
surrounding parts over which it flows. 

These vitiated ulcers are more apt to occur upon tendinous 
and aponeurotic parts, than in situations abounding with cel- 
lular membrane, owing to the frequent motion of these parts, 
and the continual agitation of the sore. Wherever an ulcer is 
seated upon a part of this character, absolute rest is necessary 
to preserve its simple and convalescent character. 

* Benjamin Bell. 



ULCERS. 93 

The cure of these ulcers depends principally upon removing 
the cause which has operated to change their character for the 
worse. If the vitiated condition depends upon constitutional 
causes, these must be combatted by the means found most suc- 
cessful in the/ practice of general medicine; if any local irritant 
has caused the evil, it must be removed as speedily as possible; 
if motion of the part has been indulged, it must be restrained. 

The local treatment consists in soothing, emollient applications, 
as it has been found that all those means which allay the pain in 
such sores, tend also to alter their condition to that of the simple 
purulent ulcer. 

When the sore is seated in the mouth, but little opportunity is 
afforded for local applications. The best, perhaps, is warm water, 
frequently taken into, and held in the mouth ; or the vapor of hot 
water received into it repeatedly and for a considerable time. 
The dentist should look closely in such cases for causes of irrita- 
tion in diseased teeth and fangs, and also ascertain whether con- 
stitutional causes are interested in the production of the trouble- 
some sore. 

The difficulty of protecting ulcers in the mouth from the con- 
tact of its secretions, and the food and drink, and the impractica- 
bility of dressing them with applications elsewhere serviceable, 
should make the dentist extremely cautious lest a careless or 
awkward movement of an instrument in his hand, should produce 
a wound and sore extremely painful to the patient, and difficult 
of cure. 

The callous ulcer. When ulcers become inactive and station- 
ary, rather than progressive, secreting but little, and that of bad 
quality, and being little sensitive, they are called indolent ; if, in 
addition, the edges become hard and thickened, they are called 
tedious. 

Very often these callous ulcers are attended with an enlarged 
condition of the veins of the part which is called varicose. This 
condition of the veins is very embarassing to the surgeon, and 
sometimes produces fatal hemorrhage. 

Callous ulcers are most common upon the extremities, and 
owing to the mechanical difficulty in the return of blood from 
9* 



94 ULCERS. 

these parts, they are, in these situations, most frequently attended 
with varicose veins. 

The callous condition of ulcers is the consequence of neglect 
and bad management. Their cure consists in restoring them as 
soon as possible to the condition of a simple purulent sore. This 
can only be done by removing the indurated surfaces. The most 
expeditious way of effecting this, is to pare away the edges and 
surface of the sore with a scalpel, thus converting the lesion 
into a wound of the simplest kind : but as few patients will sub- 
mit to the pain of this procedure, the application of caustics is 
generally preferred. 

By freely touching the surface of the ulcer with nitrate of sil- 
ver or caustic potassa, a slough is produced, which, coming away 
after some considerable time, leaves after it a healthy, granulating 
surface. 

Fungus Ulcers. — When granulations are large and pale, grow 
rapidly and rise above the level of the surrounding parts, bleed 
freely upon touch or slight pressure, and make no attempt at 
cicatrization, they are called fungus or proud flesh. Generally 
they are soft and spongy, but by very long continuance they may 
acquire considerable hardness. Fungus is not. uniformly sensi- 
tive : generally it is not at all remarkable in this respect ; occa- 
sionally, however, it is very sensitive. It is but imperfect granu- 
lation, and may arise from any cause which tends to interrupt the 
convalescence of an ulcer. Long continued inflammation of 
cellular structures and caries of the bones are very apt to be 
attended by fungus. It sometimes occurs in young and vigorous 
subjects merely as a kind of exuberant growth, which can hardly 
be considered as giving an unfavorable appearance to a sore, as 
it is readily removed by mild escharotics. 

Where fungus depends upon a mere defect of action of the 
vessels of a part, and not upon the presence of any irritating 
cause vitiating the character of the ulcer, it may be destroyed 
very readily by sprinkling upon it some burnt alum or touching it 
with lunar caustic. Fungus has not sufficient vitality to resist the 
impression made by agents of this class, and generally the appli- 
cation of the escharotic will excite the surface of the ulcer 
sufficiently to cause the growth of firmer granulations. 



ULCERS. 95 

The Sinuous Ulcer. — This name is given lo a sore communi- 
cating with long and narrow canals, penetrating the cellular mem- 
brane and running irregularly under the skin or between the 
muscles. These sinuses generally have more than one opening 
through which pus is discharged. 

Originally they are the artificial channels through which the 
contents of abscesses or the fluids produced from carious parts 
escape from parts deeply seated or so placed as to be unable to 
pass off matter in a straight line ; but the sides of the canals 
themselves becoming inflamed and secreting matter, the whole 
presents the appearance of an irregular ulcer, connected with 
some primary source of matter, and forming openings wherever 
the nature of the part causes a determination of matter to the 
surface. 

Should the sinus remain for a long time without cure, its sides 
and the edges of its orifices become hard, and it is then called a 
fistula.* This term, however, is most frequently applied to 
artificial canals which connect with some natural passage. 

The cause of sinuses is the want of a free passage for matter, 
which, seeking the most dependent point, readily penetrates the 
yielding texture of the cellular membrane and ultimately produces 
ulceration at a point distant from its source. 

The cure of these sinuous ulcers depends upon making a free 
passage for the matter in a direct line from its source, and then 
bringing the edges of the canals together and causing them to 
unite. 

If the edges and sides of the ulcer be too hard to undergo the 
necessary adhesive process, stimulating or caustic application 3 
may be used with advantage. Sometimes it is necessary to lay 
open these tortuous canals to the primary abscess, a process which 
at once gives free escape to the matter, and by exposing the sides 
of the sore to the influence of the air and proper medicinal 
applications, generally causes a wound which readily heals from 
the bottom with healthy granulations. 

Sinuses situated in the mouth should always be treated in this 
way, unless they are connected with diseased bones or teeth, or 
are so situated as to make the free use of the knife dangerous. 

* Fistula— a pipe. 



96 ULCERS. 

Carious Ulcers are those which are connected with caries or 
necrosis of bony structures. They are often sinuous, but may 
be seated immediately upon the caries which causes them. 

The discharge from carious ulcers differs from good pus. It 
is thinner and fetid, and at last becomes blackish, and often very 
acrid and irritating. Mr. Bell thought that the fetor of carious 
ulcers always afforded a sufficient means of diagnosis. 

The surfaces of carious ulcers are usually softer and more 
flabby than natural ; and instead of a florid red, they have rather 
a dark brown with somewhat of a glassy complexion. 

The granulations generally grow rapidly, but are exuberant 
and fungoid. Should the orifice heal either by the efforts of na- 
ture or the appliances of art, the apparent cure is of short dura- 
tion, for the pent-up matter soon finds another vent and produces 
another ulcer. When a probe is pushed down to the bottom of 
a carious ulcer, it generally encounters a roughness of the surface 
of the bone, which plainly indicates its eroded condition. 

When obstinate sinuses are observed in the gums, discharging 
fetid matter, and containing fungus granulations, we may always 
be assured that the cause is to be found in the presence of some 
decayed tooth or root, or to caries of the alveolus, jaw or some 
other bony structure. 

As a carious ulcer is nothing more than an accident attending 
caries, the treatment of it must always be secondary to that of 
the disease which produces it. The removal of the carious or 
necrosed part and the employment of the means which will best 
prevent a return of it, are to be regarded as the proper means of 
curing the carious ulcer. When the caries is seated in the can- 
cellated structure of bone, it can only be thoroughly eradicated 
by the terrible energy of fire, and the actual cautery must sweep 
over the diseased surface and rouse it to the exertion Of its vitality. 
When a tooth is the subject of caries, no such frightful treatment 
is necessary. The tooth being passive in the matter, and being 
acted on by chemical agents only, all that is required is to 
remove the caries and interpose between the fluids of the mouth 
and the parts of the tooth thus exposed, a barrier which must be 
impenetrable to the action of the fluids which caused so much 
mischief. The only substance by which a cavity in a tooth can 



ULCERS. 97 

be successfully filled is gold, as it only, of all the metals, pos- 
sesses both the physical and chemical qualities necessary to the 
purpose. If gold cannot be used, tin, though far inferior, is the 
best substitute. All the mercurial amalgams, are exceeding 
deleterious, both locally and constitutionally, and ought never to 
be used as dental fillings. 

The Cancerous Ulcer. — Cancer, or Carcinoma. This terrible 
affection occurs under two forms, called occult and open, or 
schirrus and ulcerative. The former variety generally, though 
not always, precedes the latter, and presents itself in the form of 
a hard, dense tumor, of slow growth, generally seated in a 
glandular structure, at first, in most cases, nearly insensible, and 
subsequently causing very sharp darting or burning pain, or 
twinges, which radiate from the schirrus as from a centre. As 
the disease progresses, the skin adheres to the tumor, corrugates 
or puckers, changes color, becoming of a livid or leaden hue, 
then ulcerates and ushers in the second stage of the disease, the 
open or ulcerating cancer. 

The ulcer thus produced is exceedingly painful and irritable. 
It discharges a thin fetid ichor, sometimes very excoriating. Its 
edges are hard and irregular, reversed and contorted. Its surface 
is generally irregular, showing depressions or excavations. The 
sore manifests no tendency to form healthy granulations, but 
spreads among the surrounding tissues which successively harden 
and ulcerate, and become cancerous. The lymphatics propagate 
the disease to the nearest glands, which are found swollen and 
indurated, and often ulcerated. 

The pain of cancer is a burning or scalding sensation, and 
generally exhausts and destroys the patient long before the 
devastation of parts can interfere seriously with the functions 
of life. 

As blood vessels are destroyed in the progress of the disease, 
bleeding, more or less profuse, occurs. 

Cancer, however, presents various appearances. We have seen 
it occur without preceding schirrus, present an equal smooth sur- 
face with little secretion; and many other appearances of this 
ulcer have been observed, as it has been modified by accidental 
circumstances. 



The characteristics of cancer may be considered to be an 
irregular, phagedenic sore, with hard reversed edges, exceedingly 
irritable under all common dressings, and causing a burning pain. 
When such a sore has resisted the treatment which is found to be 
successful in ordinary irritable ulcers, and especially when it is 
seated in a glandular part and follows schirrus, there can be no 
doubt of its malignant character. 

Cancer, in all its stages, is altogether intractable to any treat- 
ment which has yet been devised, and all but the most soothing 
applications are found to accelerate its progress and add to the 
intolerable acuteness of its pain. 

The only mode of cure now attempted is thorough extirpation, 
and this is confided almost entirely to the latent or schirrus state. 
The open cancerous sore rarely yields even to surgical remedies. 
It is even a mooted question whether the removal of schirrus tumors 
is advantageous. Some surgeons contend that where true schirrus 
is removed, cancer soon makes its appearance elsewhere, often in 
a more malignant form and in a worse location, and that the life of 
the patient is often shortened by the painful operation endured in 
hope of cure. 

It is not by any means easy to settle this question. Surgeons 
are in the habit of removing all chronic tumors which are hard 
and painful, whether they present decidedly carcinomatous symp- 
toms or not. Many of these are probably not cancerous, yet the 
operations by which they have been removed enter into the 
statistics of cancerous extirpation. 

Where but one possible hope is left, we should be very careful 
not to extinguish it, and we therefore recommend the exsection 
of schirrus tumors. To be successful, however, the operation 
must be performed before the disease has manifested activity by 
changing the surrounding parts into its own peculiar texture. 

The cause of cancer is also a matter of controversy. It is 
often excited by a wound, especially a bruise or pinch ; but this 
can only occur where there is a constitutional tendency to the 
affection. On the other hand it frequently appears without any 
exciting cause. Some writers, in view of these facts, contend 
that cancer is primarily a local affection, having a strong tendency 
to infect the whole system with its own poison. They, there- 



fore, very rationally conclude that if it be extirpated in its latent 
state, the patient may be entirely relieved from it. Others believe 
that carcinoma is a constitutional disease, manifesting itself in 
local changes of the kind described ; that it is, therefore, use-- 
less to remove the local effect, and the constitutional cause being 
beyond our control, they prefer, in the present state of medical 
science, to refrain from all attempts at cure of the disease. 

On each side of the question are presented observations and 
pathological demonstrations, and authoritative names, and without 
troubling our readers with a recapitulation of the facts and argu- 
ments brought to bear upon this subject, we will content our- 
selves with suggesting the practical inference which seems most 
rational upon the whole ; which is, that eradication of schirrus 
may be attempted with good hope, though not with certainty of 
success; that the excision of open cancer will be an experiment 
very doubtful, yet if the reports of surgeons are to be believed, 
not absolutely hopeless; and finally, that under all circumstances 
the operator must be prepared for a recurrence of the disease. 

Many specifics have been suggested for the cure of cancer, 
and many nostrums are yet vended for the purpose of curing 
these sores. All of them are useless, and most of them very 
hurtful. The medicine commonly resorted to by empirics for 
the purpose of corroding or " eating out" a cancer, is arsenic ; an 
application which adds terribly to the suffering and violence of the 
disease, and probably often produces most serious constitutional 
effects. 

We attribute to the improper application of this poison, the 
sudden death of one young lady, who, having a sore, probably of 
an ordinary kind, upon her leg, was induced through excessive 
modesty, to subject it to the treament of a famous female empiric. 

Although arsenic is useful in certain obstinate cutaneous affec- 
tions, it does not control cancer when given internally. When 
externally applied to a surface so irritable as that of cancer, it 
necessarily does great mischief. 

Cancer sometimes attacks the tongue. We saw a case of this 
kind, which seemed to have been provoked by the abrasion of 
the organ against fractured teeth. The sides of the tongue pre- 
sented a jagged edge, which gave out sanious matter. The whole 



100 ULCERS. 

body of the organ was schirrus, and the neighboring glands 
manifested a similar condition. 

A cause so slight as the retention in the mouth of a broken or 
eroded tooth, seems, in this case, 10 have been sufficient to excite 
this fearful malady, in a part, too, where the greatest possible 
inconvenience and distress must result from its presence. 

The lips, too, are very frequently the seat of cancer, and the 
dentist should be careful not to wound these very vascular and 
sensitive parts by careless or awkward handling of the sharp 
instruments he wields. 

As the several varieties of cutaneous ulcer are not likely to 
require treatment from the Dental Surgeon, we will not consider 
them, but refer the curious reader to the several surgical works 
in which they are accurately described and their proper treatment 
pointed out. 

ULCERS DEPENDENT UPON CONSTITUTIONAL CAUSE. 

Venereal or Syphilitic Ulcers.— Impure sexual intercourse has 
engendered a poison which is capable of producing local and 
constitutional disease of a distressing and dangerous character. 
With the consideration of local or primary syphilis we have 
nothing to do, but as the secondary or constitutional disorder 
develops itself in the structures of the mouth, it is necessary that 
the well instructed dentist shall be prepared to detect and treat 
it, when thus manifested. 

Syphilis usually presents itself in the form of ulcers, which are 
called chancres — it also causes cutaneous eruptions, swelling of 
glands and disease of the periosteum, fascia and bones. 

The ulcers vary considerably. Generally they are remarkable 
for their hardened base, feeling like cartilage under the skin ; 
the borders are red and sharp, the bottom greyish, and the sores 
painful and not tending to heal. 

In the throat, tonsils and mouth, the disease generally shows 
itself at once, without much previous tumefaction, so that the ton- 
sils are not much enlarged ; for when the venereal inflammation 
attacks these parts, it appears to be always upon the surface, and 
it very soon terminates in an ulcer. 



ULCERS. 101 

These ulcers of the throat are to be carefully distinguished 
from all others of the same parts. The disease in the throat is 
uniformly ulcerative; this being the first appearance of disease 
in that part.* 

The syphilitic ulcer always begins superficially, and is not pre- 
ceded by observable, or at least, by any notable degree of inflam- 
mation. This fact will be sufficient to distinguish these sores 
from the ordinary open abscess of the suppurating tonsil. 

There is also an indolent swelling of the tonsil accompanied by 
an exudation of lymph, which at first sight might be mistaken for 
an ulcer, and indeed such exudations, when they accompany scar- 
let fever, are often miscalled sloughs. They may be detached 
from the subjacent membrane, which is found unbroken. 

There is another complaint of those parts often mistaken for 
venereal, which is an ulcerous excoriation running along the sur- 
face of the parts, becoming very broad and sometimes foul, having 
a regular termination, but never going deep into the surface of 
the parts. Mr. Hunter says that there is no part of the inside of 
the mouth exempted from this ulcerous excoriation, but it occurs 
most frequently about the root of the uvula, and spreads forward 
along the soft palate. 

The same writer observes that the true venereal ulcer in the 
throat is a " fair loss of substance, part being dug out as it were 
from the body of the tonsil with a determined edge, and is com- 
monly very foul, having thick white matter adhering to it like a 
slough, which cannot be washed away." These ulcers never 
heal spontaneously, and generally spread rapidly. When the 
sores are seated upon the pharynx, they produce great distress 
in deglutition, cough and puriform expectoration, rapid sloughing 
of the soft parts, exposing the bones and destroying them even 
as far as the vertebra by caries. The palate is frequently 
destroyed, throwing the nose and mouth into one cavity, 
preventing distinct speech, and causing great discomfort and 
distress. The dentist will often be required to supply this serious 
loss of bone by an artificial substitute. 

"At other times, especially in cases of long standing, these 
sores extend not by sloughing, but by rapid ulceration. The 

* Hunter on the Venereal Disease. 
10 



102 ULCERS. 

aspect is less formidable, but its progress is scarcely less de- 
structive. This variety is most commonly seen on the soft 
palate. The surface is foul, but the slough which occupies it is 
of little depth. The sore is edged by a very narrow fringe of 
yellow slough, and beyond this for the extent of a quarter of an 
inch, there is an inflamed margin of a deep crimson color; but 
there is not much general sloughing of the surrounding parts. 
Yet the sore extends daily w r ith extraordinary rapidity. The 
substance of the part seems to melt away under the ulceration, 
and the greater part or the whole of the soft palate, is often de- 
stroyed before it can be arrested, though no distinct slough can 
be seen to separate through the whole of its course."* 

Phagedenic venereal ulcers, like cancerous sores, have thick- 
ened edges; a characteristic rather of the unhealthy character 
and spreading tendency, than of any specific quality of the sore 
itself. 

There are several kinds of venereal affections observed in the 
bones. The periosteum may be thickened and inflamed. This 
is a very painful affection, the pain being greater at night ; and 
may be mistaken for rheumatism, when the bone is so deeply 
seated as to prevent the distinct feeling of the swelling. This 
periosteal disease generally ends in permanent enlargement of the 
bony structure from deposition of bony matter. Sometimes the 
periosteum suppurates and causes exfoliation of the bone. 

Caries of the bone frequently commences in the cancellous 
structure, and gradually perforates the external plate, and then 
appears as a soft tumor, which may be seen and felt externally. 
If this tumor is laid open, a glairy fluid is evacuated ; the peri- 
osteum is found to be somewhat thickened, and the bone beneath 
is denuded, and in the centre of the denuded part, is found a 
small hole which perforates the cortical plate and communicates 
with the interior of the bone. This affection is very common in 
the skull, and may be seen in the tibia jaw and ulna. In its worst 
forms, it constitutes the worm eaten caries.f 

In determining whether a sore in the throat or a caries of the 
bones be syphilitic, it is absolutely necessary that the observer 
shall obtain all the collateral information which may aid the 

* Babington. t Babington. 



ULCERS. 1 03 

diagnosis, for it is often impossible to decide positively from 
the mere appearance of the ulcer, whether it be venereal or not. 

Very often cutaneous eruptions of a syphilitic character 
attend the venereal sore throat, and the presence of such eruptions 
would be sufficient to decide a doubtful case. 

Unfortunately, however, it is not easy to detect with certainty 
all forms of syphilitic eruption; yet, when suspicion is aroused 
by the appearance of the throat, and corroborated by that of the 
skin, or vice versa, there must be extraordinary reasons for 
inferring the cause not to be venereal. 

Syphilitic eruptions may be tubercular. That is, they may 
appear in the form of hard lumps, covered by red inflamed skin, 
and often by dead cuticle. These often ulcerate and leave behind 
them a peculiar copper colored blotch. 

Another form of syphilitic eruption, is that of small red accu- 
mulated pimples, sometimes scattered regularly over the surface, 
at others arrayed in groups. 

Scaly eruptions are also common, and sometimes a pustular 
affection attended with a large hard conical scab or crust (rupia) 
is observed. These may all be due to other causes, but when 
occurring together with a suspicious sore throat, they very much 
strengthen the probability of venereal origin. 

Mr. Hunter says, when syphilis attacks the tongue, it 
sometimes produces a thickening or hardness in the part; but 
this is not always the case, for it very often ulcerates as do the 
other parts of the mouth. 

If the character of the disease be clearly venereal, or if it be 
probably so, it is important that proper remedies be at once 
administered, for when the virus has become so generally dif- 
fused, as to produce the remote symptoms observed by the 
Dentist, the life of the patient is in imminent peril. 

There has been much controversy as to the means of curing 
syphilis, one party contending for the use of mercurial means, 
and the other denying the necessity of these medicines. 

Wiiliout pretending to any claim to decide a question so ably 
supported on either side, we will briefly remark, that mercury 
will certainly cure the disease, except in a few uncommon cases, 
where it exists in a kind of combination with scrofula; and 



104 ULCERS. 

secondly, that mercury will do this without injury to the patient, 
and generally with as little inconvenience as can attend the use 
of less certain remedies. Without hesitation, therefore, we 
recommend its use ; especially in constitutional or secondary 
syphilis, where no time must be lost, and no risks must be run. 

As to the particular preparation of mercury most proper for 
the purpose, there also is difference of opinion. As a general 
rule, however, we prefer the proto-chloride or calomel to any 
other preparation. It is more certain than blue pill, and perhaps 
than any other mercurial medicine, and can be used with more 
safety than the dento-chloride (corrosive sublimate.) Our com- 
mon practice is to give a grain of calomel, to which is added 
one-twelfth of a grain of opium, night and morning, until the 
ulcer disappears or the gums get sore. It is rarely necessary to 
produce salivation — a mere tenderness of the mouth will generally 
indicate the predominance of mercurialization in the system, and 
be attended by healing of the venereal sores, and disappearing of 
other symptoms of that disorder. 

Corrosive Sublimate in the dose of a twelfth part of a grain 
three times a day will often succeed ; and in secondary syphilis, 
is thought by some to be superior to calomel. 

When calomel acts too freely upon the bowels, as it sometimes 
does, even when administered together with as much opium, as 
it is prudent to give, corrosive sublimate or blue pill may be 
tried. Should these purge also, resort must be had to inunction; 
the patient being rubbed with mercurial ointment until his mouth 
begins to acknowledge the mercurial influence. When scrofula 
exists in union with syphilis, the iodide of mercury may be used. 

Scorbutic Ulcers. — Scorbutus is a barbarous half Latin name, 
given by medical writers to scurvy, a constitutional affection de- 
pending upon privation of vegetable food, under circumstances 
calculated to weaken the energies of the system, and which was 
long a terrible scourge to seamen, soldiers and the inmates of 
prisons. It has frequently been confounded with other affections 
a mistake which has led to serious consequences. In the year 
1700, the celebrated Boerhave treated with mercury four hundred 
soldiers thus affected and killed them all. 



ULCERS. 105 

The term scurvy, is applied to sponginess and ulceration of 
the gums from any cause, but this is an impropriety. Scorbutus 
or true scurvy, is always a constitutional affection, never occurs 
when patients have lived upon diet sufficiently vegetable, and in 
short can only be expected to occur in ships, camps or prisons; 
happily since its character has become known, it is rarely seen 
now even in these places. 

As it would be of little use to our readers, we will not intro- 
duce here a full discussion of this subject, which has ceased to 
be of much interest, even to the general practitioner; but will 
content ourselves with a very few remarks upon it, referring 
those who may be curious to know more of this subject to a very 
interesting article upon it in the Cyclopaedia of Practical Medi- 
cine, written by Mr. Kerr. 

Scurvy is a general disease characterized by debility, foetor of 
the breath, sponginess and turgidity of the gums, livid sub-cuta- 
neous spots, particularly of the roots of the hairs, echymoses, 
spontaneous hemorrhages and frequent contraction of the limbs- 

The face becomes bloated early in the disease, and the lips are 
of a pale greenish hue. The countenance looks sad; the patient 
complains of extraordinary lassitude and becomes breathless after 
slight exertion. The gums soon become swollen, itch and bleed 
upon touch ; they are deep red, soft and spongy: soon fungus and 
putrid. Bleeding occurs frequently from the mouth and other parts, 
and the breath is very offensive. The skin is usually smooth 
and shining, with a suffusion of black or livid spots. Old wounds 
or sores break out afresh, and ulcers frequently occur. 

These sores secrete a thin fetid sanious fluid ; their edges are 
generally livid and puffed up; a coagulum soon forms, which with 
great difficulty, can be wiped away or separated from the subja- 
cent parts. These are soft, spongy and putrid.* A soft bloody 
fungus, of considerable size, soon rises from the ulcer. When 
scurvy approaches its fatal termination, the livid and painful 
swellings break and assume the fungus appearance characteristic 
of scorbutic ulcers. The hemorrhage becomes more profuse and 
general; the increasing dyspnea is accompanied in some cases 

* Cyclop. Prac. Med. 
10* 



1 06 ULCERS. 

with pain under the sternum, but more frequently in one of the 
sides. In others, however, without any complaint of pain, the 
respiration becomes suddenly quick and laborious, and death 
unexpectedly puts a period to the disease. 

The prevention and cure of scurvy consist simply in providing 
a proper vegetable diet, and keeping the patient warm and dry. 
Where this cannot be done, as is the case at sea, the purpose can 
be effected by administering lemon juice freely, and making the 
men as comfortable as possible. Medicine has little to do in the 
matter, though it may render occasional aid. It is always 
important to distinguish the symptoms of scurvy from those of 
other diseases ; fortunately there is no longer much danger of 
mistakes in this respect. The subject does not belong to prac- 
tical dentistry, though the disease of the gums connected with it 
make it proper for us to mention it ; our chief purpose in doing 
so, however, is that our readers may have a proper knowledge of 
the meaning of a word which is continually misused by dentists 
by applying it to a local fungus affection. 

Scrofulous Ulcer. — Scrofula. This word is derived from the 
Latin word Scrofa, a hog — why, it is not easy to perceive; but 
it is singular that the corresponding Greek word is also derived 
from a word (x u( p0 signifying a hog. 

Whether those who originally described the disease were aware 
that swine are subject to it, or whether, as is most probable, they 
intended to portray the dirty appearance of those afflicted by it, 
we have no means of determining. Scrofula is also known as 
Struma, and the word Strumons is frequently used instead of 
Scrofulous. 

Scrofulous tumors and ulcerations are also vulgarly called 
King's Evil, from the loyal superstition which for many years 
attributed to the touch of a sovereign the miraculous power to 
heal the disease. Multitudes of cases were touched by the 
monarchs of England, from Edward the Confessor to Queen Anne. 
A similar practice existed in France. 

Scrofula is a constitutional disorder which manifests itself in a 
great variety of local affections, and is among the most distressing, 
and in some of its forms, the most fatal oi all the ills that flesh is 
heir to. 



ULCERS. 107 

The pathology of scrofula is not well understood. It seems to 
affect particularly the lymphatic system ; the glands, especially 
the subcutaneous and mesenteric, being most frequently the parts 
which first manifest the local influence of the constitutional vice. 
Very often, however, its ravages are confined to internal organs. 
The lungs are especially liable to be affected by it, assuming that 
well known and so far incurable diseased condition, which is 
called phthisis* or pulmonary consumption. 

Although persons of all temperaments are subject to scrofula, 
yet those who possess what is called the lymphatic temperament, 
are much more liable to it than others; and as this system is pre- 
dominant in children and women, they are more exposed to 
scrofula than adults and men. 

Yet men are by no means exempt, but those of the male sex 
in whom the lymphatic temperament predominates, are most 
liable to it. 

It is common to distinguish the scrofulous disposition by certain 
external marks which doubtless indicate, with considerable accu- 
racy, the presence of the constitutional vice. These appearances, 
from the strong disposition to phthisis which they manifest, are 
frequently called " consumptive." 

These marks are a fine white skin; light hair; rounded plump 
figure; delicate complexion, with rosy cheeks; large lips; large 
lower jaw ; yellowish teeth, or teeth, whatever their color, which 
are soft and easily attacked by caries ; a large head ; straight and 
narrow chest ; large abdomen, and soft and flabby flesh. Persons 
presenting these external appearances are generally amiable, and 
oflen very sprightly and intelligent, and among them are found 
the loveliest and most attractive of the female sex. 

The strumous diathesis is exhibited, in another class of persons, 
very differently. In these the complexion is dark, the skin harsh 
and the habit indolent ; the countenance is swollen and pasty, and 

# Phthisis, from <pdww — I consume — Consumption. There are several 
chronic diseases of the lungs, which are vulgarly knowa as consumption. 
Most of these are inflammatory affections and their consequences. Phthisis, 
or consumption proper, is an entirely different disorder in its cause and char- 
acter. It is, with few exceptions, incurable from the commencement. The 
inflammatory affections are all curable, if promptly and rightly treated. 



108 ULCERS. 

all the functions of the body are sluggish and imperfect ; the 
nervous energy is feeble; the feelings are obtuse, and the moral 
and intellectual powers occupy a very low rank. Scrofulous 
cases of this character are not by any means uncommon in Britain 
or the United States, although far more rare than the other 
variety, but extreme instances are frequent in some districts of 
Switzerland and France; and in these, human nature appears 
reduced almost to the level of the brute creation, assuming forms 
which awaken feelings of humiliation and disgust.* 

Appearances, such as described as characteristic of either of 
the two classes of scrofulous subjects, are not necessary to the 
development of scrofula ; but when these marks present them- 
selves, nothing but the action of circumstances most favorable to 
counteract the threatened evil, can prevent its appearance. 

Scrofula is the consequence of damp, cold climates, bad diet, 
and want of exercise and fresh air. These circumstances, when 
combined, may engender the disease in any child, but in most 
cases it is hereditary, being transmitted from the parent; whole 
families being frequently destroyed by this fatal legacy. In one 
recorded instance, in which the father and mother were both 
strumous, eight children out of nine died in childhood of scro- 
fulous affections. 

The scrofulous disease manifests itself in a variety of ways. 
In glandular swellings, sluggish ulcers, distorted bones, cutaneous 
eruptions; but the most common and the most characteristic 
attendant upon scrofula, is the production of a soft cheesy, unor- 
ganized matter, which is found mixed with the pus of abscesses 
or deposited in rounded masses of different degrees of firmness, 
and of various sizes, called tuberculous matter. Sometimes this 
is enclosed in cysts, sometimes diffused throughout a part, and 
sometimes it is found in the natural canals or cavities of the body. 
To the depositions of this matter and the irritation and inflam- 
mation which it produces, are due the most serious consequences 
of scrofula. 

Scrofulous ulcers are generally consequent upon tumors of the 
same character. These, after having been indolent for a consid- 
erable time, at last ulcerate and discharge their softeaed contents. 

* Cumin. 



ULCERS. 109 

Instead of healing, the orifice enlarges and an ulcer is established, 
discharging a thin glutinous fluid, occasionally intermixed with the 
peculiar cheesy or curdy substance already described. 

Commonly, scrofulous sores are not painful ; occasionally they 
are so. The skin around them is livid and slowly ulcerates ; the 
granulations are flabby and pale, and their margins are usually 
overlapped by the thin unhealthy looking skin. The matter often 
hardens about the sore, and presents a disgusting appearance. 
The ulcer heals slowly, and the cicatrix is irregular, puckered 
and wrinkled, " with small portions of projecting skin and even 
complete bridges, admitting a probe to pass beneath them ; 
features by which their origin, long after a cure, may be readily 
discovered." 

As one ulcer heals, another is often ready to break out, and the 
patient is gradually debilitated and worn down by the incessant 
irritation and drain. Sometimes the disease manifests itself in a 
vital organ, and by speedy death curtails the sufferings of the 
patient. 

To scrofula seems properly to belong a very serious ulceration 
of the lips, nose, &c, which is called lupus, or nolle me tangere. 

This disease commonly commences by the appearance of a 
hard, livid tubercle, which, after being indolent for a longer or 
shorter time, ulcerates, and produces ichorous, wasting, ill-con- 
ditioned sores, which, in some instances, (lupus exedens,) rapidly 
destroy the adjacent parts ; in other cases, lupus induces a sort of 
hypertrophy of the skin. Sometimes the first appearance of the 
disease, is a mere violet red color, tending rapidly to ulcerate and 
destroy the surrounding parts. 

The tonsils of scrofulous persons, are very prone to chronic, 
indolent swellings, which, upon slight provocation, take on acute 
inflammation. The glands in the neck, and the sublingual and 
submaxillary glands, are often affected by scrofula ; forming hard, 
painless, indolent tumors, which sometimes suppurate, causing 
intractable ulcers, which, after pouring out the glutinous and floc- 
culent matter peculiar to this kind of sores, heal with the irregu- 
lar, puckered, ugly cicatrix before described. 

Dr. Cumin says that scrofula occasionally attacks the tongue. 
It sometimes assumes the form of aphthous ulcerations, and 



110 ULCERS. 

fissures of the margin, but its most characteristic features are 
small knots or nodules, superficially imbedded in the subslance ot 
the organ, varying in size from that of a small shot to that of a 
horse bean. They cause no uneasiness, unless when firmly 
pressed, and then the pain is slight and pricking. The mucous 
membrane covering them, is red and prominent, and soon breaks 
iu the centre, giving rise to an ulcer, which spreads and destroys 
by sloughy erosion, with much pain, profuse salivation, furred 
tongue, and fetid breath. The ulcers under proper treatment, 
become clean, contract and heal ; but the hardness remains : fresh 
nodules form in other parts of the organ, and the same train of 
suffering is gone through, after a longer or shorter interval, ac- 
cording to the state of the patient's health and the regularity of 
his mode of life, until a decided improvement be produced on the 
constitution by time, change of climate, or the employment of 
remedies. 

The mucous membranes of scrofulous persons, are apt to in- 
flame, and generally pour out mucus in large quantity, and often 
of an acrid quality; not unfrequently the mucous membrane of 
the mouth presents aphthous exudations, excoriations and small 
ulcers. 

We have already mentioned that the texture of the teeth of 
scrofulous persons is of that character which makes them an 
easy prey to caries. When we remember that teeth thus little 
capable of resistance are continually exposed to the action of 
unusually abundant and acid mucus, we may readily account for 
the ravages of caries upon the mouth of persons of scrofulous 
taint. 

Scrofula sometimes attacks the bones of the face, especially 
the nose, causing, when the disease is confined to a very small 
portion of osseous tissue, the intolerably fetid sore called czena, 
and when acting upon a large surface, horrible devastation and 
deformity. The bones of scrofulous subjects are more slender, 
the outer wall thinner, and their inner more soft and vascular 
than the bones of others. 

Syphilis, however, is the more common cause, both of ozena 
and osseous destruction, but it is in subjects of scrofulous consti- 
tution that it produces its most fearful and irresistible effects. 



ULCERS. Ill 

The care of scrofula depends much upon hygienic treatment. 
As experience shows that cold, humid climates are most favora- 
able to it, one of the best means for preventing and curing its 
disorders, is evidently removal to a warm, dry climate. Be- 
sides this, which is often impracticable, exercise in the open air, 
generous diet, and the use of such medicinal remedies as are cal- 
culated to invigorate the frame, are the best means by which to 
combat this obstinate and most serious affection. 

Iodine is the best medicine we possess for removing the super- 
ficial glandular obstructions, and healing the ulcers of scrofula. 
It often exerts a sanitary influence upon these and similar external 
manifestations of scrofula. Unfortunately the high hopes enter- 
tained at one time of the power of this medicine to cure the 
radical constitutional evil, or even the most fatal form of its de- 
velopment, tubercular phthisis, have been totally disappointed. 
This terrible form of scrofulous malady yields little to therapeutic 
agents, and, for the most part, is checked only by the hygienic 
means before referred to. Cod liver oil is now much used in 
scrofulous, and especially phthisical cases, and seems to benefit 
them, either through some unknown medicinal principle, or, as is 
more probable, through the concentrated and highly nutritious 
aliment it affords to the wasting tissues. 



CHAPTER VIII. 

TUMORS. 

The term tumor, literally means a swelling, and is often used 
in this wide sense, but it is more properly restricted to such 
enlargements as depend upon morbid growth, either of the natural 
parts, or of matters not natural, formed in the tissues of the body. 
This definition rejects such swellings as are produced by the 
presence of free fluids and gases. 

Tumors may be divided into malignant, and those which being 
comparatively innoxious, may, for want of a better term, be 
called benign. 

The malignant tumors are such as depend upon some constitu- 
tional vice, and, resisting all remedies, tend to convert the sur- 
rounding tissues into their own substance. These spread rapidly, 
ulcerate, destroy the blood-vessels of the part, produce fre- 
quent and exhausting hemorrhages, are sometimes very painful, 
and if permitted to remain, ultimately fatal. 

Cancer, or carcinoma, and fungus hsematodes, or bleeding fun] 
gus, are the general names for these tumors, though distinct 
names have been given to varieties of each of these disorders. 

We have already sufficiently noticed cancer as it affects the 
soft parts, but there is a form of it, or at least an analogous dis- 
ease, which affects the bones, especially those of the face ; and 
of this disease, called osteo sarcoma,f it is important that we 
should take some notice. 

By osteo sarcoma, is meant a malignant disease of a bone, in 
which there takes place within it a growth of fleshy matter, 
which distends the bony walls, and gradually converts the 
structure into a medullary, cartilaginous, or cancerous looking 
substance. 

*Tumeo, I swell, f Oonov a bone, and <rxg% flesh. 
11 



116 TUMORS. 

pressure upon the lachrymal sac ; the hearing impaired by the 
obstruction of the eustachean tube, and the voice changed by the 
stoppage of the nostril. The swallowing begins to be impeded 
by the depression of the palate ; the bones become carious from 
the steady and increasing pressure ; the tumor projects from the 
nostril before and over the arch of the palate behind ; the nose 
is twisted ; the countenance distorted ; the patient suffers with 
terrible headaches — a foul and fetid matter is discharged from 
the nostrils ; alarming hemorrhages ensue ; the floor of the 
antrum begins to give way; the teeth fall out and matter issues 
through their sockets; the still increasing pressure constantly 
aggravates the sufferings of the patient until death closes the scene. 

Though all polypi, from their tendency to grow, may in time 
produce all the terrible train of symptoms above enumerated, yet 
we cannot agree with Mr. Bell, that all are essentially similar. 
They differ very much in color, density and tendency to return. 
Some are pale and so loose in texture as to be almost vesicular ; 
others are red, hard and resisting, &c. But in all cases they must 
be removed, and it is of little use to distinguish between them. 

There are four ways of extirpating nasal polypi : extracting 
them with forceps; tying them with ligatures; cutting them out, 
and destroying them with caustic. The manner of performing 
these several operations is described in the books on general 
surgery. It is not within our province to recapitulate them. 

Benign Tumors. — Those which have no tendency to spread 
by converting adjacent tissues into their own substance ; which 
do not depend upon constitutional vice, and may be considered 
as mere local aberrations from healthy growth. Of these there 
are several kinds, which may be reduced to two classes, the 
Sarcomatous* and Encysted Tumors and Exostoses. 

Sarcomatous or fleshy tumors are known by their firm, red 
and fleshy feeling. (Some of the malignant tumors are arranged 
by Mr. Abernethy under this class.) There are several varieties 
of them, of which the common Vascular and the Adipose or 
fatty are, by far, the most common. 

These tumors grow to great size; are not painful, and may be 
handled with impunity. Their size and situation, however, often 

* 2cc&— flesh. 



TUMORS. 117 

make it necessary to remove them. If permitted to pursue their 
natural course, they sometimes suppurate, and then subside. This 
mode of cure, however, involves so much inconvenience, that it 
is commonly better to extirpate them. 

Encysted Tumors, or as they are commonly called, Wens, have 
this peculiarity, that their contents are contained in a cyst, or sac, 
or bag. The contents of the cyst are various. Sometimes the 
contained matter is fatty, in which case the tumor is called a 
Steatoma* Sometimes it is a yellowish, thick substance, some- 
what like honey or a mixture of honey and wax. Tumors of this 
kind are called Melliceris.f When the contents are like fluid 
cheese or pap, the tumor is called Jltheroma.'l 

The contents of these tumors, however, are not always of such 
a quality as will permit them to be classed under the names above 
mentioned. It is not necessary, however, to be more precise. 
Perhaps, for all practical purposes, it had been as well to have 
permitted them all to wear the popular designation, Wens. 

These encysted tumors are common about the head, and fre- 
quent upon the eyelids. They are generally globular, not sensi- 
tive and cause no inconvenience beyond what is inseparable from 
their weight and size ; and the trouble from these causes will, of 
course, depend upon their location. They usually grow slowly, 
but sometimes attain great size. Sometimes the skin above them 
ulcerates, and the tumor is thus evacuated. This does not very 
frequently occur. These tumors should always be removed by 
dissecting them out, being careful not to leave any portion of the 
cyst behind — for if this caution be neglected, the disease is 
liable to return, and does not always present, upon its second 
appearance, the benign character which characterized it origi- 
nally. The operation should always be performed when the 
tumor is small, for obvious reasons. 

The mode usually adopted in the extirpation of these tumors 
is to dissect out the sac with the contents entire. Owing to the 
yielding nature of the contents, this is a tedious and troublesome 
process. Sir Astley Cooper recommended to cut through the 
sac at once, and then to dissect it out ; and doubtless this is the 

* lrex ? — fat. J A6r)g* — pap or pulp. 

| MsXi, honey, and K>>po£,wax. 



118 TUMORS. 

more easy method, inasmuch as the divided edges of the cyst 
may then be held by the forceps. Encysted tumors occurring 
in the mouth should be attended to as soon as they are perceived. 

Bony Tumors. — Exostosis* — An enlargement of the bone by 
the addition of osseous matter within its cavity or upon the 
surface. There are several varieties, denominated ivory, lame- 
lated, &c, according to the density of the tumor and the 
disposition of its particles. 

The bones are liable to other forms of tumefaction, which 
differ from exostosis, although often confounded with it. When 
the bones are enlarged by mere distension or separation of their 
parts, the disease is not at all similar to the dense tumor produced 
by the presence of an unnatural quantity of bony substance. 

Thickening of the periosteum sometimes occasions an apparent 
enlargement of the bone, when in fact the osseous matter is not at 
all increased or distended. 

Sir Astley Cooper described exostosis as having two different 
seats, viz : between the external surface of the bone and the 
periosteum, constituting periosteal exostosis; and in the medullary 
membrane and cancellated structure, forming medullary exostosis. 
Sometimes he found the production of bone preceded by car- 
tilage, in which it was deposited ; at other times connected with 
a fungus of a malignant character, containing spicula. This latter 
form of disease seems to have been a variety of osteo sarcoma. 

Exostosis may occur upon any of the bones, and the cause of 
the disease is generally inscrutable; depending upon irregularity 
of ultimate nutrition, a process which cannot be comprehended. 

The structure and consistence of exostosis present great dif- 
ferences. Sometimes, especially when the tumor is not very 
large and when situated on the surface of a cylindrical bone, one 
may trace with the eye the diverging of the osseous fibres in the 
interspaces, of which we might say that there is deposited a new 
bony substance, the organization of which is less distinct. Some- 
times the tumor is entirely cellular, and formed of a few broad 
laminal intercepting extensive spaces, which are filled with mat- 
ter, different from the medulla, and of various quality. This case 
is denominated the laminated exostosis. 

* Eg out of 05-raov — a bone. 



TUMORS. 119 

portion of bone makes a sort of hollow sphere, with thick, hard 
walls, the cavity of which is filled with fungus granulations, 
more or less extensive and indolent. According to Boyer, this 
variety of the disease differs essentially from osteo sarcoma, not- 
withstanding external appearances. The case here alluded to, 
Mr. S. Cooper considers the same as that which Sir Astley has 
named, cartilaginous exostosis of the medullary membrane.* 

In this last described form of exostosis, Sir Astley Cooper says 
that the original shell is absorbed and a new one deposited, and 
within the ossified cavity thus produced, a very large mass of 
elastic, firm and fibrous cartilage is formed. This form of 
disease is not malignant, but often ends in very extensive disease. 

A true exostosis, consisting of dense bony matter, and of mode- 
rate size, may exist without much inconvenience to the surround- 
ing parts, provided they be of a kind to endure the degree of 
pressure without distress. But where the exostosis is so situated 
that its bulk can only be accommodated by pressing upon dense 
and unyielding structures, or upon nerves or blood-vessels, or 
where the enlargement impedes muscular motion, these tumors 
may occasion very serious consequences. The action of the 
flexor muscles of the leg has been seriously interfered with by an 
exostosis in the neighborhood of the knee. An exostosis of the 
orbit has displaced the eye. Sir Astley Cooper narrates a case 
of this kind, where two exostoses, growing from the antra, 
pushed out both eyes, and finally produced death by pressure 
upon the brain. In another instance an exostosis of the sixth or 
seventh cervical vertebra, stopped the circulation in the radial 
artery by pressing upon the subclavian, and in another a cartila- 
ginous exostosis of the medullary membrane of the lower jaw 
extended so far back, that it pressed the epiglotis down upon 
the rima glottidis, and destroyed the patient.f 

The causes of exostosis are various, and, for the most part, 
little understood. The venereal disease is frequently attended 
with the formation of bony enlargements, or nodes, but this can- 
not by any means be considered the ordinary, or indeed a fre- 
quent cause of other forms of exostosis. 

* Cooper Surg. Die. + Surgical Essays. 



120 TUMORS. 

In some individuals there is an unusual tendency to the irregular 
deposit of bony matter, and provocations, otherwise trivial, will 
often determine local osseous enlargements. Sometimes these 
provocations are perceived, as when they consist in some form 
of external force, as blows, pressure, &c; more frequently the 
determining cause is as obscure as the constitutional vice. 

Exostosis is always very hard, sometimes painful, often insen- 
sible. The firm resistance of the tumor, and its adhesion to a 
bone, will generally enable us to distinguish it from other tumors. 

Exostosis is commonly gradual and slow in its growth, but the 
fungus, or medullary swelling of the bones, is often rapid in its 
development. The latter form of disease is attended with very 
severe pain, and often with much constitutional irritation. 

Exostosis of the Teeth. 

The fangs of the teeth are more frequently the seat of exosto- 
sis than any other part of the osseous structures. This affection 
often causes great suffering to the patient, and the dentist finds in 
it one of the most common and troublesome impediments to safe 
and easy extraction of the teeth. 

The disease is always developed upon the root; generally at 
the extremity, sometimes upon the sides ; frequently the whole 
fang is involved, though not so equally as to present a symmetri- 
cal enlargement. 

Mr. Thomas Bell says that the substance thus added, differs 
from the natural bone, being harder, yellowish, and slightly trans- 
parent. As the swelling progresses, the pressure on the alveolus 
causes the latter to be absorbed, and thus, as the growth is very 
slow, room is continually made for the enlarged fang. The 
wasting, however, being propagated to the tooth, soon exposes 
the cavity to the action of external agents, and tooth-ache leads 
to extraction. Mr. Bell says that the continued irritation some- 
times occasions thickening of the periosteum and suppuration, and 
the case becomes one of simple alveolar abscess. 

Exostosis of the fangs, sometimes occasions neuralgic suffering 
of a very serious grade and long duration, the cause of which is 
rarely discovered by an ordinary observer. Sometimes the 



TUMORS. 121 

adjacent parts become functionally disturbed, and multiply the 
points of suffering. Mr. Fox relates the case of a young lady, 
who had suffered long with this affection of the fangs, which her 
medical attendants had entirely overlooked. The eyelid of one 
eye had not been opened for two months, and the secretion of 
saliva was so abundant from the irritation that it flowed out 
whenever the mouth was opened. 

Professor C. A. Harris has recorded the following case :* 

Mr. S., of Baltimore, having suffered from pain in the left 
superior bicuspis, applied to a dentist in 1843, for the purpose of 
having this tooth removed. In the operation the root was frac- 
tured, about three-sixteenths of an inch from its extremity, and 
the upper part left in the socket. The pain continued, and at the 
expiration of twelve months the gum over the upper part of the 
alveolus, became very much swollen, puffing out the upper lip to 
half the size of a hen's egg. The tumor was opened, and a large 
quantity of dark-colored very fetid matter was discharged, which 
for a short time afforded considerable relief. The tumor, how- 
ever, soon re-appeared, and was opened four or five times in as 
many months. 

In the fall of 1845 he called on Dr. Harris for advice. The gum 
was swollen, and the lip and cheek protruded in the manner above 
described. The tumor was opened again, and about three table 
spoonsful of black matter, resembling thin tar, was evacuated. 
Upon farther examination, the outer wall of the antrum, immedi- 
ately over the upper part of the alveolus of the bicuspis, which 
had been fractured, was destroyed, leaving an opening large 
enough to admit the end of the forefinger. Believing that the 
extremity of the root left in the socket, was the cause of the 
mischief, Dr. Harris cut away the outer wall of the alveolus, and 
removed the fragment. The root of the tooth was found exos- 
tosed. The patient recovered completely in a few weeks. 

A great number of cases, illustrating the variety and extent of 
mischief occasionally resulting from exostosis of the teeth, are 
recorded by writers upon the subject. The dentist when con- 
sulted for the relief of pain in the teeth or jaws, especially if of 
long Continuance and obstinate persistence, should always seek 

* Dictionary of Dental Science, article Exostosis. 



122 TUMORS. 

carefully for evidence of bony enlargement of the fang. It is a 
very common disease, and in some individuals affects many, or 
even all their teeth simultaneously. Sometimes exoslosis unites 
several teeth together. In a specimen presented to the Baltimore 
College of Dental Surgery, by Dr. G. R. Hawes, of New York, 
the three superior molar teeth of one side, are thus united. In 
another specimen, presented by Dr. Blandin, of Columbia, S. C, 
two upper molars are united ; and in a third, presented by Dr. 
Ware, of Wilmington, N. C, there is a deposition of bone on the 
roots of a first superior molaris, as large as a hickory nut. Simi- 
lar specimens are in the museum of the Institution. 

The disease admits of no cure, and the exostosed tooth must 
be extracted. In performing the operation, caution is necessary 
lest in the effort to tear away the enlarged bulb, the alveolus, or 
adjoining teeth, or a fragment of the maxillary, be brought with 
it. It is often necessary to cut away the socket in order to liber- 
ate the root. 

TUMORS OCCASIONED BY ENLARGEMENT OF BLOOD-VESSELS. 

1. Jlneurismal* Tumors. 

A tumor caused by the distension of the walls of an artery, or 
of the heart, is called a true aneurism ; if the swelling be due to 
the rupture of an artery and the extravasation of blood in the 
surrounding tissue, it is called a false aneurism. 

An aneurismal tumor may generally be detected by the throb- 
ing or pulsating sensation which it communicates to the hand 
upon pressure. Sometimes, however, when an abscess happens 
to be seated over an artery the pulsation of the latter will be 
communicated to the former. The pulse often indicates the ex- 
istence of an aneurism of the heart, or some large artery by a 
peculiar thrilling sensation, which has been aptly compared to the 
feeling of a " shattered quill. 1 ' As fatal accidents have occurred 
from thoughtlessly opening tumors of this description, it is always 
important to examine every tumor carefully before thrusting a 
lancet into it. 

The pathology and treatment of aneurism, does not come 
properly within the scope of the present work. 
* Avevpsvvtiv — to dilate. 



CHAPTER IX. 

DISEASES OF THE TEETH AND FACE DEPENDENT UPON MORBID 
CONDITIONS, EITHER GENERAL OR OF OTHER PARTS. 

Neuralgia.* — Certain nerves are the organs of sensation, and 
like other parts of the body they are liable to disease. When 
such is the case, unless the affection be of a kind to lessen their 
sensibility they become the seat of very severe suffering which 
is called neuralgia. 

It may be asked whether all painful sensations are not seated 
in the nerves? we answer that they are; yet the distinction be- 
tween neuralgia and other pains, is that in the case of the former 
the nerves are concerned primarily rather than as instruments ; 
or in other words, they transmit intelligence of their own suffer- 
ing, (for such is pain) not that which is only shared by them with 
adjacent parts. We must not expect philosophical definitions in 
medicine. The term neuralgia is not precise, but it is sufficient 
for practical distinction. 

The superficial nerves being by far the most sensitive, and 
withal, the most exposed to injury, are very much more frequently 
affected with neuralgia than those which are deeply seated. It 
is not certain whether the seat of the disease is in the neurilemma 
or the nervous pulp. In fact the ultimate nature of the nerves is 
too little known to permit us to hazard an opinion upon this 
subject. 

Neuralgia is a very acute pain which generally commences 
suddenly, and occupies a single spot, from which as the attack 
progresses in violence, it radiates by pangs or flashes to the sur- 
rounding nerves. The pain is generally sharp and darting or 
burning, and maybe distinguished, among other characteristics, by 
this, that in its radiations it follows the threads of the nerves with- 
out extending to the adjacent structures. There is no heat, red- 

* Nft^ov a nerve and aXyogpain. 



124 NEURALGIA. 

ness nor swelling, the absence of which are sufficient to distin- 
guish the disease from inflammation. The pain after continuing 
for a longer or a shorter time, rarely longer than a few hours, 
abates, generally suddenly, and disappears to return with equal 
rapidity if the proper provocation be repeated. 

The proximate cause of neuralgia is unknown, as indeed is its 
pathology. There are two varieties of it, which may be termed 
pure and intermittent. 

By pure neuralgia we mean that variety which is not, so far as 
we know, connected with or dependent upon any other affection, 
general or local. 

This disease generally occurs in pale, thin and feeble persons, 
and seems to be a disease of debility. The pain for the most 
part comes on suddenly, and gradually increases to great intensity, 
when either in obedience to remedies, or through the action of 
unknown laws, which regulate the ebb and flow of nervous in- 
fluence, it abates rapidly and leaves the patient entirely free from 
suffering. It does not return until some provocation be applied, 
when it will suddenly re-appear and will not be appeased for 
several hours. Nor is it necessary that any powerful irritant be 
applied in order to rouse the nerve to renewed agony. Often the 
slightest cause will be sufficient; the gentle movement or touch of 
the part, and especially the slightest breath of cool air will often 
be sufficient to renew the terrible pain. 

The intermittent neuralgia is a symptom, and often the only one 
of ague, or intermittent fever, as it is commonly called, but which 
in this case must drop the latter word as there is no fever present. 
Of this disease we must speak at length presently. 

Neuralgia of each kind may be located in various nerves. The 
scope of our work makes it necessary for us to notice but one 
speciality of the disease. 

Neuralgia Faciei or Facial Neuralgia. 

To this subject we would particularly invite our readers, as it 
is one which it is most important for all dentists to understand. 
The reason will be seen in the sequel. 

Neuralgia faciei is sometimes called tic doloureux. The word 
tic means a sudden twitching or convulsive movement, and as this 



NEURALGIA. 125 

is sometimes noticed in the faces of persons suffering with 
neuralgia of that part, the term tic doloureux or painful tic, was 
given to the affection. 

Neuralgia faciei is seated in some of the branches of the fifth 
pair of nerves, and the first and second branches are more com- 
monly its seat. The pain is therefore most frequently suffered 
over the orbit, in the cheek, mouth, lower jaw and lower teeth. 

It will be perceived at once that the dentist must often be 
called upon to discriminate between this disease and ordinary 
tooth-ache, and that unless he be properly informed upon these 
subjects he may add to the terrible suffering of his too confident 
patient, the additional anguish of tooth extraction and the injury 
of losing sound and most valuable organs. 

In most cases the neuralgia of the nerves of the jaw is at first 
mistaken for tooth-ache and frequently ignorant dentists have ex- 
tracted tooth after tooth, and have at last relinquished the patient 
to his aggravated suffering. 

The diagnosis of this malady is not difficult. From all acute 
inflammatory conditions it may be readily distinguished by the 
absence of all the other symptoms of inflammation except pain, 
and by the peculiar character and direction of the pain. The 
fact that it subsides, disappears and returns, will also serve to 
distinguish it from the continued pain of inflammation. 

From tooth-ache depending upon exposed nerves, it may 
be diagnosed by the evident centralizing of the pain in a 
certain tooth, by the aggravation of it when the tooth in fault is 
struck and by the positive evidence of a cavity in it, with an ex- 
quisitely sensitive pulp exposed. 

The treatment of pure neuralgia faciei is palliative and curative. 

The palliative treatment consists in the use of such means as 
are calculated to allay the pain of the paroxysm. The curative 
consists in the employment of such remedies as experience has 
shown to be most useful in restoring the health of the patient 
Of palliative means, warmth is one of the most important. Cold 
aggravates the pain intensely, and will almost always excite a 
paroxysm of pain in a patient subject to neuralgia. Warm or even 
hot applications to the face are therefore important aids in allay- 



126 NEURALGIA. 

ing the suffering. Counter irritants, such as mustard plasters, 
blisters, cupping, &c, are also occasionally useful. 

But our main reliance for the relief of neuralgic pain, is in the 
use of narcotics* or anodynes,f and especially of opium which is 
vastly superior to all the rest. 

It is necessary to give this medicine in full doses, if we would 
benefit the patient under these circumstances. An adult should 
take two grains of opium, or sixty drops of laudanum, and in some 
severe cases, or when the patient has become accustomed to the 
effects of the drug, this dose will require increase or repetition. 

The curative treatment of pure neuralgia will be modified by 
circumstances. If the patient be plethoric with a red face and 
active pulse, even general and local bleeding may be premised. 
Such, however, is rarely the case, and when it is we have reason, 
to believe that the disease is rather rheumatic than neuralgic. 

If the digestion be bad, which is often the case, correctives 
must be directed to the organs involved. But in most cases the 
restoration of healthy digestion will not be sufficient to procure 
permanent relief. 

Generally, neuralgia is a disease of debility, and is found in the 
cold, pale and feeble, and in persons of evidently broken health. 
In such cases the tonic medicines offer most advantage, and of 
these none are found to be so useful as the salts of iron. 

There are several preparations of this medicine. The carbon- 
ate, if properly prepared, is a good form for administering iron, 
but by far the most valuable preparation is the sulphate. This 
has also the advantage of being generally good as found in the 
shops, and of benig always readily procured. It is much more 
certain and efficient than the other ferruginous preparations. 

It may be given in doses of a grain two or three times a day, 
and must be continued for several weeks. Under its use the 
patient will generally improve in strength and color, and with 
the invigoration of the general system, the neuralgic affection 
will frequently disappear. If this medicine should disagree with 
the patient or if it should fail after a fair trial, recourse may be 
had to other medicines of the tonic class, of which there are 
many, mineral and vegetable. 

* Narcotics from vxpxou I stupify. f Anodyne from * privative ofuvr] pain. 



NEURALGIA. 127 

It is a very common thing for authors and practitioners to con- 
found the pure and intermittent neuralgias, through want of dis- 
criminating periodicity from a tendency to return upon slight 
provocation. Yet the distinction is plain and very important, for 
upon proper diagnosis of the form of the disorder depends the 
rational treatment of it. 

In pure neuralgia the nerve after the subsidence of a paroxysm 
is left in an exceedingly irritable state, so that it will be excited 
to another by causes of irritation in themselves exceedingly 
slight. But this return is merely accidental and occasional, and 
of course, obeys no law of regular occurrence. In some instances 
the exciting cause may be so trivial as to escape notice, but after 
long and painful experience, the patient learns to perceive potent 
agents for evil in things which previously eluded observation 
altogether. 

Periodicity, is the regular return of paroxysms in accordance 
with a law of the disease and independently of provocation. It 
generally observes fixed periods of return and departure, and 
when irregular as to the common law which governs the type to 
which it belongs, it obeys some regulation of its own, by which 
some well defined proportion of paroxysm to intermission is pre- 
served. It does not follow then, that because the neuralgic pain 
abates either of itself or under narcotics and recurs in a few hours 
or days, that consequently it is periodical and must be treated 
by quinine. 

Intermittent Neuralgia. — In order to understand the character 
and treatment of this disease, it is necessary to have a correct 
knowledge of a particular, class of fevers which present very 
curious phenomena. 

These fevers belong to the class which we have designated as 
idiopathic; and to the family of malarious or marsh fevers. 
They are commonly known as agues, from the fact that each 
paroxysm is preceded by a chill. Hence, also they are known 
popularly as chills and fevers. 

The cause of these affections is always malaria, no other 
agent or combination of circumstances produces them, and this is 
so true that the fact of exposure to malaria is most important in 
deciding upon the character of the disease in mooted cases. 



128 NEURALGIA. 

Malarious neuralgia always assumes the intermittent, never, as 
far as I know, the remittent type. It may appear as a quotidian, 
tertian or quarter, or it may be irregular in its periods. Its 
paroxysms are rarely preceded by chill, accompanied by fever, or 
perceptibly finished by a sweeting stage. Though evidently 
depending upon the same cause as intermittent fever, it has no 
phenomena in common with the former, except its paroxysmal 
character, periodicity and curability by certain specific means. 

In endeavoring to ascertain the cause of violent intermitting 
pains in the face, it is all important to learn whether the 
patient has previously been exposed to malarious influence. If 
it shall appear in any instance that he has not been out of the 
central part of a large city, known to be free, at least in such 
part of it, from all emanations of a malarious kind, this fact is 
abundant evidence that the patient has not intermittent neuralgia, 
however strong appearances may be to the contrary of this 
opinion. On the other hand, if he lives in a marshy or malarious 
country, or if he has visited such a locality during the latter part 
of the preceding summer or early part of the fall, and especially 
if the patient has had well marked ague previously to the facial 
suffering, then the presumption will be very strong in favor of 
the malarious origin of the disease. 

Besides this historical kind of evidence, the attending circum- 
stances will shed much light on the case. If there be no ap- 
parent cause in the condition of the teeth of the affected jaw for 
so much suffering, if no other disease can be detected in the bones 
or soft parts, if the pain intermits perfectly and returns periodi- 
cally, or even if not with entire regularity, yet obviously with 
some obedience to the law of type, and without provocation, all 
these circumstances taken together will leave little doubt as to 
the nature of the malady. 

Cure. — This distressing malady, which, if misunderstood, is one 
of the severest and most difficult to alleviate or endure, is when 
properly diagnosed a very manageable affection and often yields 
to the very first dose of well directed medicine. 

We have previously remarked that the pathological cause of 
intermittent febrile phenomena was not known ; fortunately for 



NEURALGIA. 129 

the world, experience has not waited for pathology but has 
pointed out the means of relief and the mode of applying it. 

Certain medicines are known to be positive antidotes to inter- 
mittent malarious fevers of all kinds. These agents if exhibited 
freely during the intermission, rarely fail to prevent the return of 
the paroxysm. Owing to the fact that most of these medicines 
possess tonic or roborant qualities, it has been supposed that 
they check intermittents, through this quality. Hence, tonics 
are said to cure ague. 

We are convinced, however, that the supposition which at- 
tributes the prevention of intermittent paroxysms to the common 
roborant quality of tonics is a mistake, and a mistake which pro- 
bably has led to unfortunate consequences in practice. 

The medicines which possess in the greatest degree the anti- 
dotal power to intermittents, are not those which are the best 
tonics ; while the best of all roborant medicines have but little, if 
any power, to check intermittent paroxysms. 

Cinchona, or Peruvian bark, is by far the best anti-intermittent 
remedy we have, yet as a pure tonic it certainly is vastly inferior 
to iron, and hardly equal to some of the vegetable bitters; while 
arsenic, which, next to cinchona, is the most powerful anti-par- 
oxysmal medicine of which we have any knowledge, has no tonic 
property at all. 

The anti-intermittent quality is therefore obscure, and the 
medicines under consideration are prescribed for the cure of these 
diseases, simply because experience has clearly proved their 
preventing quality, and not because we perceive any rational 
relation between the physiological effect of the medicine and the 
pathological condition to be removed. 

In the treatment of intermittent neuralgia, we must rely upon 
the medicines named, or, if these fail, upon others of the same 
class. Generally, however, if cinchona and arsenic have failed, 
we must look to some other quarter than to this class of means 
for an efficient remedy. 

The best mode of administering cinchona, is in the form of the 
sulphate of quinine, because the dose is very much smaller, and 
sits better upon the stomach, and because, moreover, the cinchona 
12* 



1 30 NEURALGIA. 

in bulk is uncertain in strength. The best form of administering 
the quinine, is in solution, although pills of it are often given. 

In order to dissolve it perfectly in water, it is necessary to add 
a few drops of sulphuric acid or elix. vit. 

The dose varies very much with the circumstances of the case. 
Thus if the intermission be long, a considerable time is afforded 
between the paroxysms, for the introduction of the antidote, and 
small doses, frequently given, are preferable ; if, however, but 
little intermission is afforded, the dose of the medicines must be 
proportionally greater. 

The dose, also, must vary with the urgency of the case, and 
the condition of the patient. If he has already suffered long, has 
been much reduced, and has but little power of resistance left, 
the dose should be very decided. 

There is also considerable difference of opinion among practi- 
tioners upon this subject. Some prefer giving large single doses, 
or at least rarely repeated ; others, small doses, frequently re- 
peated. 

Generally speaking, either mode will effect the desired result ; 
but as it is plain that we should give the least quantity of medi- 
cine that will be sufficient, I am in the habit of prescribing 
moderate doses of quinine, and have never found them to fail 
except when the stomach refused to bear them; in which cases 
larger doses would have been yet more objectionable. 

The prescription of quinine which I generally give, is a solu- 
tion of ten grains of quinine, dissolved in an ounce of water. A 
teaspoonful, containing a grain and a quarter of quinine, being 
given as a dose to an adult. 

This quantity is given every two hours, if there be an inter- 
mission of considerable duration, or every hour if the time for 
administering be short. 

In very serious cases of intermittent, involving great danger to 
the patient, and when the powers of life were low, I have very 
much exceeded the quantity above named. Some practitioners 
always give it in doses of ten or twenty grains ; but this quantity 
is unnecessary, and hardly safe ; for though many patients would 
bear it without inconvenience, some would suffer from its action 
upon the brain. 



NEURALGIA. 131 

The dose of quinine to young children, must always be very 
small, as their nervous system is more excitable, and their brain 
more easily disturbed, than is the case with adults. 

Next to quinine, arsenic is our most certain antidote to inter- 
mittent affections. It is given in the form of the arsenias potass, 
or Fowler's mineral solution, in which form it is manageable, and 
in proper doses entirely safe. The virulently poisonous character 
of arsenic, renders it improper to attempt its administration in 
any but a diluted form. 

There are many cases in which the arsenic appears to exercise 
the anti-intermittent power quite as efficiently as cinchona, and 
the small bulk of the dose, and the readiness with which its flavor 
may be covered, make it far preferable for administration to 
children. 

It may be given very advantageously in alternate doses with 
quinine. After it has been persevered in for a long time, it is apt 
to produce oedema, which readily subsides when the medicine is 
withdrawn. The dose of Fowler's solution, to an adult, is eight 
or ten drops, every one, two, or three hours, or alternating every 
four hours with quinine. Sometimes it produces nausea and irri- 
tation of the bowels. In such cases the dose should be lessened. 

There are many other remedies, which are more or less effica- 
cious in the prevention of intermittent paroxysms, but it is not 
necessary to mention them here. 

The quinine and arsenic should be given only during the inter- 
mission; though if this be very short, the administration of rem- 
edies, and especially of the arsenic, may be recommenced before 
the fever has entirely subsided. 

In the treatment of intermittent neuralgias, as in other inter- 
mittent affections, the prevention of a paroxysm will be more 
certain, if a full dose of opium be given an hour before the ex- 
pected return. 

In cases of intermittent neuralgia, where the patient has been 
exposed to malaria for successive years, and has suffered much 
from the diseases attributed to this cause, the liver and other 
abdominal viscera, are generally deranged, and the neuralgia 
cannot be permanently relieved until these visceral obstructions 
are overcome. 



132 NEURALGIA. 

The purgative preparations of mercury, are very useful in 
such cases. 

Of course, no permanent cure can be expected, while the 
patient shall continue to reside in the unhealthy location, as he 
musl, of necessity, be exposed to continual renewal of the dis- 
ease. Unfortunately the advice of medical men, is rarely of 
much avail in directing the choice of residence. This is deter- 
mined, for the most part, by considerations entirely independent 
of health ; and there is great difficulty in persuading a man 
that it is unsafe for him to live where it is most profitable or 
pleasant, and that his own property is situated where nobody 
ought to live. 



CHAPTER X. 

MORBID SECRETIONS OF THE MOUTH. 

Six glands, the parotid, submaxillary, and sublingual of each 
side, pour their secretions into the cavity of the mouth. The 
mucous membrane, which lines the organ, also contains upon its 
surface a great number of crypts, or follicles, which prepare and 
pour mucus into the mouth. The secretions from the glands 
and mucous membrane, form saliva, which lubricates the facial 
cavity, and in mastication is thoroughly mixed with the food, the 
subsequent digestion of which it materially aids. 

The mucous membrane of the mouth, is continuous with that 
which lines the pharynx, aesophagus, stomach, and intestines, and 
sympathizes greatly with any diseased condition which affects 
those organs. Hence the furred tongue in fever, the red tongue 
of intestinal irritation, &c. 

The fluids of the mouth, are readily changed from their nor- 
mal condition, when the digestive organs are feeble, and perform 
their functions badly. When such is the case, the secretion of 
the stomach and its appendages are so changed as to unfit them 
for the perfect performance of their work ; they become, to a 
certain extent, foreign matters, and are capable of exciting irri- 
tation, and also by mixing with alimentary matters, converting 
them into deleterious agents. Generally the change produced 
upon the fluids of the stomach, &c, under such circumstances, 
renders them more acid. 

Corresponding changes often take place in the fluids of the 
mouth. They also become acid, and in such cases corrode the 
dental structures, and cause great devastation of the teeth. 

They are also liable to be produced in excess, and to be very 
abundant in salts, which are collected, mixed with viscid mucus, 
about the teeth, especially of the lower jaw, forming the several 
varieties of tartar. 



134 MORBID SECRETIONS OF THE MOUTH. 

The saliva of healthy persons, is only sufficient for comfort- 
able lubrication of the mouth, and being passed into the stomach 
as fast as it forms, it does not collect in the mouth, or require to 
be frequently excreted. When healthy, it is light, frothy, and 
but little viscid, without odor, floats upon, and mingles readily 
with water. In this condition it is slightly alkaline. 

The saliva is acid in dyspepsia, and consequently caries is apt 
to prey upon the teeth of persons suffering with indigestion. Nor 
may the dentist expect to arrest the devastation, unless he can 
remove the cause that is continually decomposing the bony struc- 
tures of the teeth. 

That the saliva is acid in certain diseases, is abundantly shown 
by Mr. Donne, of Paris, — who was so struck with the changes 
in the chemical character of the fluids of the mouth, as responding 
to disordered slates of the stomach, that he suggested the use of 
this fact, as the best means of deciding upon doubtful cases of 
such disorders. 

M. M. Tiedemann and Gmelin,had previously found the saliva 
to be alkaline in man, and all other animals whose secretions they 
had examined. Magendie, with his usual carelessness of facts, 
and boldness of theory, taught that the saliva was sometimes 
strongly alkaline, sometimes neutral, and sometimes acid : when 
the stomach is empty, the fluids of the mouth, according to this 
writer, are acid; during mastication, alkaline ; the acidity dis- 
appearing sometimes at the presence of the fust mouthful. The 
latter part of this opinion, is, of course, mere nonsense. 

According to M. Donne, who seems to have investigated this 
matter with great carefulness, with the hope to find in it some 
semeiological fact, which might lead to great practical results, 
the saliva is constantly alkaline when the stomach is in a healthy 
condition. This, then, he considers the normal or natural quality 
of the fluids of the mouth, and all deviations from it, he considers 
unhealthy, and indicative of gastric disease. M. Donne declares 
that he has never found the saliva acid, when the stomach has 
performed its functions well. 

The only testing means used by this gentleman in his many ex- 
periments upon the saliva, were slips of litmus paper. The 
saliva, if acid, will redden the paper: lor test of alkalescence the 



MORBID SECRETIONS OP THE MOUTH. 135 

paper should first be reddened by an acid and then subjected to 
the action of the saliva. 

M. Donne narrates a number of cases of various forms of 
disease, in all of which the stomach was deranged and the saliva 
acid. We will quote a few of them. 

A young woman was admitted into the hospital of La Charite, 
laboring- under severe bronchitis, attended with great tenderness 
of the abdomen, excessive irritability of the stomach, diarrhoea, 
ardent thirst, &c. The saliva was strongly acid. The disease 
assumed in its progress a marked typhoid character, the tongue 
was parched and coated with a brown crust, the abdomen was 
always very tender; delirium and coma supervened and the 
patient died on the tenth day after admission. The saliva was 
acid during the whole course of the illness. Dissection showed 
extensive disease of the mucus membrane of the stomach and in- 
testines. 

A young man was received into La Charite, as a fever patient. 
All the symptoms of ataxic fever soon developed themselves. 
The saliva during the first days was only slightly acid but later 
it became more strongly so; he died comatose. The saliva re- 
mained acid to the end. Dissection showed a fifth part of the 
mucous membrane of the stomach diseased. 

A young man was admitted into the hospital as a fever patient. 
The symptoms were not serious, there was a yellow hue of the 
skin; the epigastrium was rather tender on pressure, there were, 
however, neither vomiting nor diarrhoea present, the tongue was 
white and the saliva was alkaline. During the progress of the 
case the saliva became acid, continued to be so for three days, 
then became neutral, and as the patient recovered, gradually re- 
sumed its alkalinity. 

In the case of a young man who exhibited the symptoms of 
gastritis, namely, great tenderness of the epigastrium, thirst, 
tongue red and parched, &.c. the saliva was found to be decidedly 
acid. By repeated leechings of the abdomen, and the use of 
demulcent and refrigerant drinks, the symptoms were speedily 
relieved, and in a few days the saliva was quite neutral, having 
no effect either on the simple litmus paper, or on that which 



136 MORBID SECRETIONS OF THE MOUTH. 

had been previously reddened by an acid. It soon regained its 
alkalinity. 

This patient had two relapses of his complaint, and on both 
occasions the saliva was acid at first, and became neutral, and 
then alkaline, as the symptoms disappeared. 

From these and similar facts, M. Donne inferred that acidity of 
the saliva was always attendant upon gastric disorders of a febrile 
character. 

Professor Harris informs me that repeated experiments have 
satisfied him that the acidity is confined to the mucous secretions 
of the mouth ; the secretions from the salivary glands never red- 
dening the litmus held to the mouth of their ducts. 

Schill observes that "carious teeth indicate long-continued 
irregularities of digestion. The teeth become very sensible 
(sensitive) in many nervous diseases, and in consequence of the 
presence of acid in the stomach. They are sometimes covered 
with a whitish or grey mucus: this occurs chiefly in catarrhs, and 
inflammations of the digestive and respiratory organs."* 

When we remember the extreme susceptibility of the teeth to 
be decomposed by the action of acids, (see page 31,) we may 
well understand why caries is so general, and so hard to arrest. 
Providence has made the saliva alkaline, in order to protect the 
important organs it bathes, from injury by acid matters taken into 
the mouth, and also to moderate the acidity of the gastric fluids. 

But under many morbid conditions, especially those most com- 
mon to artificial life, the protecting fluid itself becomes the 
assailant, and the teeth exposed at once to the attacks of acid 
aliments and drinks, and to the more constant action of acidulent 
saliva, soon yield to those corrosive agents. 

This acid state of the saliva may accompany a vitiated condi- 
tion of the fluids of the stomach, when no gastric suffering has 
attracted the attention of the patient, and the existence of any 
disorder in that organ has not been suspected. In such a condition 
of things, however, the dentist can afford only temporary relief, 
unless, perceiving the evil himself, he suggests such remedies as 
may relieve the patient of it. 

* Schill's Semeiology, 



MORBID SECRETIONS OF THE MOUTH. 137 

The practitioner of dentistry should, therefore, be always pre- 
pared to test the quality of a patient's saliva, as regards acidity 
or alkalescence ; and he should also be prepared to give such 
advice as may be necessary, in consequence of any discoveries 
he may make. 

When diseases of an acute character exist there will be no 
demand for the services of the Dental Surgeon, unless his me- 
chanical assistance be required. It is not necessary, therefore, 
for us to treat of such affections. But it often will happen, that 
a patient will apply for operations upon the mouth, who may be 
affected with some sub-acute or chronic disease of his stomach, 
for which he is not under medical treatment. If the disorder be 
not very trifling, the dentist ought, in such cases, always to advise 
application to a judicious physician. But it will often happen, 
that the patient cannot conveniently procure such attention, or 
that the dentist may not have such confidence in the skill of the 
medical practitioner who could be procured, as to authorize him, 
as a conscientious man to devolve the case upon another. He 
must therefore give the necessary advice himself.; 

In calling the attention of the dental student to the considera- 
tion of dyspepsia,* as a common name for chronic diseases of the 
stomach particularly characterized by indigestion, we do not 
think we are in any degree leading our readers away from the 
studies proper to them. 

Dyspepsia or indigestion, representing any derangement of the 
function by which the aliment, after having been received into 
the stomach, is converted into chyle, must necessarily present a 
number of appearances, more or less characteristic of the particu- 
lar trouble they represent, and the degree of its violence. It is 
therefore impossible to furnish a description sufficiently accurate 
and comprehensive to cover all the conditions of defective diges- 
tion which are included under the common name dyspepsia. Sev- 
eral complicated organs are concerned in the process of digestion. 
These are connected together by the natural dependence of recip- 
rocal necessity, and by powerful sympathies ; and any of them, 
when diseased, may interrupt the functions of the others. To 

* Dyspepsia — Avs with difficulty, and IIswtw — I digest. 
13 



138 MORBID SECRETIONS OF THE MOUTH. 

understand this subject well, it will therefore be necessary to 
have a complete knowledge of all the morbid conditions of all 
the organs of digestion, and of all the means likely, under any 
circumstances, to be useful in restoring them to healthy action. 

Of course, it is not our purpose to discuss this subject in all its 
fulness of detail. It will be sufficient to impart such practical 
information, as may be easily remembered, and readily made 
availing by the dental practitioner. 

The symptoms of dyspepsia vary much with the duration and 
nature of the affection, the constitution of the patient, his mode 
of life, &c. 

Generally the appetite is capricious, sometimes very feeble. 
Heartburn, a sense of weight or distension in the stomach after 
eating, incapacity of digesting certain substances, such as oily 
matters, pastry, &c, costiveness, abdominal pains, weakness, 
depression of spirits, &c. are most prominent. 

From the extensive sympathies existing between the stomach 
and brain, head-ache is a very common attendant upon dyspepsia. 
This is often very violent, and attended by nausea and vomiting. 
The patient soon learns by experience that he cannot take certain 
articles of food or drink with impunity, and every deviation from 
the diet suitable for him, is attended by renewal of symptoms, 
and aggravated suffering. 

Dyspepsia may be variously classified for the purpose of 
description and treatment, but the simple, plain and practical dis- 
tinction laid down by Dr. Eberle seems preferable for our pur- 
pose to any of the more accurate, yet more complicated arrange- 
ments presented by other writers upon this subject. According 
to Dr. Eberle, dyspepsia may depend upon two distinct morbid 
conditions of the digestive organs, viz : 1. On functional debility 
of the stomach from deficient or vitiated secretion of the gastric 
fluid, and muscular inactivity, independent of vascular irritation 
or inflammation. 2dly. On deficient or vitiated secretion of the 
gastric fluid with vascular irritation or chronic inflammation of 
the mucous membrane of the stomach and duodenum, and a mor- 
bidly increased peristaltic action of these organs. 

The characteristic symptoms of the former grade of indiges- 
tion, are weak appetite : tongue covered with white fur : absence 



MORBID SECRETIONS OF THE MOUTH. 139 

of epigastric tenderness, except after a paroxysm of colic from 
flatulent distension; costiveness ; acid and fetid eructations; 
absence of habitual tension and febrile irritations of the pulse ; 
and the ability of bearing lean and tender animal food better 
than vegetable and farinaceous articles of diet. 

The phenomena which characterize the second or inflamma- 
tory grade of the disease, are tenderness to pressure of the epi- 
gastrium, and particularly about the region of the pylorus and 
duodenum ; a red, chopped, granulated or glossy appearance of 
the tongue; a firm, tense, small and somewhat accelerated pulse, 
with slight manifestations of febrile exacerbations towards even- 
ing; emaciation; irregular action of the bowels, with frequent 
attacks of mucus, bilious or watery diarrhoea ; violent protracted 
pain in the lower part of the epigastrium during the process of 
digestion; fullness about the edge of the false ribs on the right 
side ; an anxious and discontented expression of the counte- 
nance; and inability, without great suffering, to endure animal 
food and stimulants. It appears that the irritative or chronic 
inflammation of such cases is seated in the mucous membrane of 
the pyloric extremity of the stomach, and of the doudenum, con- 
nected usually with a congested state of the liver and often with 
foecal accumulations in the colon.* 

The causes of dyspepsia are : 

1st. Hereditary predisposition. Some families inherit from 
their parents some peculiarities in the intimate organization of 
the stomach which inevitably result in dyspepsia of protracted 
and aggravated character, which makes its appearance about or 
soon after puberty, and continues with more or less intermission 
for years. This predisposition, however, is not of very frequent 
occurrence. 

2d. Mental and moral causes, such as exaggerated passions ; 
gloomy habits of thought ; depression of spirits ; over anxiety 
of mind. 

The influence of the feelings over the stomach is well known. 
Grief destroys the appetite, so do joy and ardent anticipation. 
Fasting is a natural exponent of sorrow. 

3d. Irregular living, especially the artificial life of the fashion- 

* Eberle's Prac. of Medicine. 



140 MORBID SECRETIONS OF THE MOUTH. 

able world, which turns night into day and day into night; rob- 
bing the body of sleep when most disposed to and best prepared 
for it, and forcing the stomach, at unnatural hours, to eat heartily 
of the most indigestible and irritating kinds of food, if such 
ingesta can thus be called without impropriety. 

4th. Luxurious and excessive eating and drinking, both of 
water and intoxicating drinks. 

5th. Sedentary living without sufficient exercise. 

6th. Unwholesome and insufficient diet. The use of pickles 
in excess, especially by delicate females. 

7th. Want of healthful and sufficiently laborious occupation. 
It is owing to this, together with the adjuvant action of other 
causes which we have mentioned, that so many of the young 
women of our country are feeble, diseased, useless and short- 
lived. 

8th. The abuse of medicines, especially those of a purgative 
character. People have a wonderful disposition to be actively 
purged. Millions of pills, containing irritating and powerful 
cathartics, such as jalap, scammony, aloes, calomel, gamboge and 
croton oil, are annually sold to persons whose only disease is too 
frequent purgation. The result often is chronic and incurable 
dyspepsia. 

9th. Eating too fast, so that the gastric juice does not mingle 
with the food as rapidly as it is taken. Imperfect mastication, 
generally because of carious teeth. 

10th. Extensive disease of the teeth, occasioning frequent 
and severe tooth-ache, vitiating the secretions of the mouth, and 
thus furnishing to the stomach saliva of a bad quality. We have 
just seen that imperfect mastication may cause dyspepsia. Exten- 
sive caries interferes much with mastication. Moreover, pain 
disturbs digestion, and frequent tooth-ache not only produces 
the common effects of pain, but from the position of the suffering, 
interferes with insalivation and regular eating. 

11th. To all these causes may be added every thing which 
tends to exhaust the vital energies, as every kind of excess 
necessarily does. 

The treatment of dyspepsia consists first, in removing as far as 
possible all the causes of it. It will be useless to make an 



MORBID SECRETIONS OP THE MOUTH. 141 

attempt to cure, unless the patient will make patient and self- 
denying efforts. 

The patient must he contented to subsist upon such food as he 
can readily digest. The diet should be as dry as possible, for all 
drinks dilute the gastric juice, and when this is vitiated or 
deficient, dilution renders it still less efficient. 

As to the character of food, it is exceedingly difficult to lay 
down a bill of fare which will suit all cases. The stomach, in 
dyspepsia, is very capricious. Some patients will eat with impu- 
nity what others cannot digest at all. I once had a dyspeptic 
female patient whose stomach revolted at the most simple and 
digestible substances, yet retained and digested comfortably, 
apple pie and milk. Generally, the patient has learned, by- 
repeated experiments, what food agrees best with him, and to 
this he should be confined. 

In general, when the disease is simply one of debility without 
gastric inflammation, animal food answers better than vegetable. 
In selecting the particular kinds of animal food, we should avoid 
young meats. Veal, lamb, and young pork are very indigestible 
by weak stomachs. The mode of preparation also is important. 
Soups of all kinds are pernicious, as they present the food to the 
stomach very much diluted and mixed with oily matters. Oils 
in all forms must be avoided, hence fried food, melted butter, 
gravies, most kinds of fish, &c, are inadmissible. All acid fruits, 
and the whole family of nuts, come under similar condemnation. 
Sugar is very apt to sour upon the stomach, especially if it be 
dissolved in warm water, as in the form of sweetened tea and 
coffee. 

In these cases of debility of the stomach, a little brandy taken 
at dinner is often very serviceable. The remedy, however, is a 
dangerous one, and no prospect of advantage from it should 
induce us to advise it to one who has at some previous time been 
intemperate in its use. It is better for a man to be a dys- 
peptic than to be a sot; and reformed inebriates have seldom 
a choice between abstinence and excess. Indeed, every patient 
who may be advised by his physician to use ardent spirits, 
should be faithfully warned against the danger of acquiring an 
intemperate love of alcoholic excitement. 
13* 



142 MORBID SECRETIONS OF THE MOUTH. 

The medicinal treatment of such cases consists in the employ- 
ment of such occasional purgatives as may be necessary to pro- 
cure regular alvine evacuations ; in the proper use of mild mer- 
curial means to an extent sufficient to remove torpor of the liver; 
in the administration of alkalies, if the patient be troubled with an 
excess of acid ; and finally, in the use of suitable tonics. All pur- 
gative medicines are not by any means equally well suited for the 
purpose we have indicated. Those of them which are very 
harsh and irritating, and those which produce watery and exhaust- 
ing discharges would be very injurious to dyspeptics. Indeed, 
we have enumerated the abuse of these cathartics among the 
common causes of the disease. 

Rhubarb, from its aromatic and tonic quality, and its mildness, 
is one of the best medicines for habitual use, under these circum- 
stances. Aloes is somewhat stimulating to the torpid intestine 
and generally acts very gently upon the lower bowels. Blue 
pill mixed with either of the medicines above named, will often 
prove very advantageous, and calomel given occasionally in a 
decided dose will be very serviceable when the liver is indolent, 
and its secretions deficient either in quantity or quality. 

Of the vegetable tonics, the pure bitters, such as quassia and 
gentian are the best. But the preparations of iron are more 
likely to be decidedly advantageous. 

We must not, however, expect a great deal from medicine in 
the relief of dyspepsia. At most it is a secondary means of cure. 
The removal of the causes and the rigid adherence to regimen, 
will, in most cases, ultimately procure relief. 

It is very important that the teeth of dyspeptic persons be care- 
fully examined, for often the cause or at least a cause of the 
disease may be found in the diseased and defective condition of 
these organs, and a speedy cure be obtained by their removal. 

As to the form of dyspepsia attended by sub-inflammatory con- 
dition of the lining membrane of the stomach, its cure must be 
devised upon the principles which govern in the treatment of 
similar conditions elsewhere. Moderate antiphlogistic means 
and mild farinaceous diet, will generally be attended with perma- 
nent relief, nevertheless the gastric surfaces, as the mucous mem- 
branes elsewhere, after having been inflamed remain subsequently 



MORBID SECRETIONS OF THE MOUTH. 143 

very susceptible to renewal of the disease, and the patient when 
relieved must be very careful not to presume upon the comforta- 
ble feeling of his stomach, and introduce into it stimulating meats, 
condiments or liquors. 

All dyspeptic persons should be advised to eat slowly and 
chew their food well. If the absence or bad condition of the 
teeth interfere with mastication as they will often be found to do, 
the skill of the dentist must supply the deficiency or repair the 
injury of those important organs. 

Dyspepsia or indigestion, expresses only the mal-performance 
of an act which is the result of the combined effects of various 
organs. Therefore, as failure of function in any one will inter- 
rupt the healthy completion of the great common purpose, 
dyspepsia must be a general term comprising several disorders. 
Being immediately connected with the digesting apparatus, and 
in fact forming an important part of that great and complicated 
system by which aliment is received and prepared for assimila- 
tion, the dental apparatus can hardly escape injury when the 
other organs of this system are involved in suffering. Indeed, 
the mucous membrane, which in the stomach and intestine is the 
seat of the digesting process, and in the mouth is continually 
pouring out important fluids from its surface and glands, is so 
intimately connected with the dental arch as to unite it in close 
sympathy with the more important organs of alimentation. A 
healthy state of the fluids of the mouth is necessary for the safety 
of the. teeth, and the secretions of the mouth will not be healthy 
when the functions of the intestinal canal membrane are disturbed. 
It is a hopeless task to save the teeth from caries while the 
patient suffers unmitigated dyspepsia. 

Syphilis, also, by vitiating the general glandular and secreting 
systems, may produce a state of the buccal fluids very inimical 
to the structure of the teeth. This will only be the case in those 
secondary or constitutional forms of lues of which we have 
already written sufficiently when treating of ulcers. 

Rickets very much delays dentition, and so impairs the struc- 
ture of the teeth that when protruded they are very liable to 
decay. 



144 MORBID SECRETIONS OF THE MOUTH. 

The enamel of teeth formed under the influence of this constitu- 
tional vice, is often craggy and worm eaten in appearance, though 
sufficiently hard. The fang during the progress of the disease, 
has been found somewhat softer than natural. 

The exanthemalous febrile affections, which commonly occur 
in childhood, interrupt the regular deposit of bony matter in the 
growing teeth, and cause permanent defects which are sometimes 
discernible in the external appearance of the organs. 

Measles, for instance, often leaves evidences of its visit upon 
the enamel of the teeth, in the pitted appearance which they 
present. 

As fever of all kinds is always attended with vitiation of the 
secretions of the mouth, we may readily perceive how any pro- 
tracted disease of this kind may injure the teeth. 

All serious diseases of the antrum must involve the dental arch. 
Inflammation may be propagated, nutrition impeded, caries com- 
municated and the arch actually broken up in the course of those 
often fatal diseases which have their seat in this geographically 
important cavity. 

The surgeon dentist should be well acquainted with the various 
disorders and morbid growths which may be developed in the 
antrum. Early detection is often necessary to cure, and none is 
so likely to have the opportunity of early discovering the hidden 
mischief, as the dentist. The first symptoms of the disorder are 
often felt in the teeth, and unless the dentist who may be con- 
sulted shall be able to point out the true nature of the evil, delay 
may be occasioned, and delay may be fatal. 

Mercurial salivation, (ptyalism) has often caused extensive 
devastation in the dental arch. Mercury, like all other of hea- 
ven's boons has been shamefully abused, and serious and even 
fatal injuries have resulted from the reckless administration of 
this most useful medicine. Unhappily, the occurrence of such 
calamitous accidents, has induced such general and unreasonable 
prejudice against the use of mercurial medicines, that vastly 
more evil is now suffered by society from the improperly with- 
holding, than injudiciously using them. The feeling against 
mercury has been the common hobby-horse of charlatans and un- 
principled physicians, and it needs no little firmness to enable a 



MORBID SECRETIONS OF THE MOUTH. 145 

physician to deal honestly with his patient in the use of this drug. 
From the fact that salivation is injurious to the teeth, dentists 
have been led to comment severely on the use of calomel, and 
thus have done much to spread abroad terrible notions of the 
evils inseparable from the employment of this and other mercu- 
rial preparations. Some of these censorious gentlemen have 
seen evidences of mercurial devastation in every form of disorder 
and variety of decay ; and to them calomel is the one thing to be 
avoided by all who live to eat, or eat to live. 

Doubtless salivation, especially if profuse, must be destructive 
to the teeth, fortunately it is at length understood that ptyalism is 
not, by any means necessary to the attainment of all the benefit 
of mercury. Salivation is an accident always to be dreaded, and 
as far as possible to be avoided. Yet even at the risk of it mer- 
curial remedies are indispensable, inasmuch as life is more im- 
portant than teeth. 

There is no reason to believe that the use of mercury is 
injurious to the teeth, when salivation is not induced ; yet 
caries of these organs is very often attributed to it. People 
are exceedingly apt to confound the post hoc with the propter 
hoc,* and dentists are as liable as other men to fall into the error. 
A patient who has escaped a severe attack of fever, finds his 
teeth rapidly decaying; in great alarm he applies to the dentist. 
The latter glances at the mouth and with a look of boding sagacity, 
inquires if the patient has not been taking calomel. The patient 
replies that he has been taking more or less, and then the man of 
science, as he is presumed to be, launches forth for the hundredth 
time into a bitter diatribe against mercury as the origin of all 
evil. 

And why might not the lamented caries be as justly charged 
upon the tartar emetic or magnesia, which the patient may have 
taken simultaneously with the calomel? or why does not the 
dentist seek for the all sufficient cause of devastation in the fact 
that the teeth in question had been bathed in the acid saliva of a 
fevered mouth for weeks consecutively ? Why transfer the 
blame to the remedy by which the fever was subdued, and cast 

* To consider whatever occurs subsequently, to be consequent upon what 
has been observed to precede it. 



146 MORBID SECRETIONS OF THE MOUTH. 

implied and serious censure upon the physician, whose judicious 
employment of the villified drug has, perhaps, saved the patient's 
life? 

Until we have other information than we now possess, we 
cannot believe that the proper employment of mercury is injurious, 
and while we reprobate its abuse and would think the physician 
unpardonable, who would be careless or reckless in the use of a 
medicine capable of doing so much harm, we cannot but regard 
that man as the author of greater evil, who by silly declamation 
against an important remedy, fetters the physician in his contest 
with the most formidable diseases. 

Scrofula, to which we have already called attention, interferes 
with assimilation, and consequently with the completeness of 
nutrition and growth. Being often inherited and developing its 
mischievous nature very early in life, it influences the teeth during 
the important process of formation, and by preventing their per- 
fect organization renders them feeble to resist the influence of 
morbific causes. 

This evil consequence is, however, generally conterbalanced by 
the thinnesss and deficiency of mucous and salivary fluid, and the 
difficulty with which the fluids of the mouth of strumous persons 
become acid. 

Pregnancy is supposed to be fraught with danger to the teeth. 
Indeed, this opinion has been sufficiently general to have become 
condensed in the adage — "for every child a tooth" — meaning that 
the mother may expect to lose a tooth as the result of each 
pregnancy. 

Pregnancy is not disease, it is a physiological condition, and 
we cannot believe that it is per se, and naturally a cause of 
disease any where, especially in organs distant and not immedi- 
ately dependent upon the uterus. But in pregnancy the nervous 
system is irritable, and the sympathies of the body are in more 
lively play. The vascular action is also greater and the blood is 
more highly charged with fibrine. It therefore happens that 
there is more liability to pain then than at other times, and less 
patience to endure it. Consequently, if the woman has any dis- 
eased teeth, previously neglected, they will be apt to ache, and 
when aching, the pain to her irritable nerves is intolerable. Be- 



MORBID SECRETIONS OP THE MOUTH. 147 

sides this, there is occasionally a sympathetic tooth ache, which 
though it cannot be directly traced to the uterus, certainly 
depends upon its gravid condition and not upon disease of the 
tooth itself. The dentist should be aware of this; it is readily 
alleviated by an anodyne. 

It also happens very frequently that the artificial life and the 
absurd habits of our young females, induce a constitution but 
little capable of sustaining child-bearing, although to the woman 
of good health and vigorous frame, parturition is fraught with no 
disadvantage to health or shortening of life. These pallid, soft 
and delicate girls, when become pregnant, begin rapidly to break 
down, and the rapid caries which destroys their teeth is but the 
first manifestation of the premature decay of the whole body. 
This is a subject upon which we could and would willingly write 
much, but it would be useless. 

Fashion, custom, inclination will bear sway over reason and 
moral obligation, — years of comfort will be sacrificed for hours 
of mirth, — showy dress and ball room vigils will continue to 
feed the insatiable tomb with the loveliest of our race. 



CHAPTER XT. 

MORBID EFFECTS OF CONDITIONS OF THE TEETH, AND THE PARTS 
IMMEDIATELY CONNECTED WITH THEM, UPON THE GENERAL 
SYSTEM. 

Having considered the several forms of disease in other parts, 
or of the general system, which morbidly affect the teeth, we 
proceed to inquire what effect these latter organs, in their varied 
states, whether physiological or pathological, may induce in other 
parts, and what changes they may cause in the more general 
phenomena of vital action. 

As the body is a unit, knit by the closest bonds, pervaded by 
one system of blood-vessels and nerves, directed by one intelli- 
gence, and kept in a continual relation of function and expression 
by an all pervading law of reciprocal re-action and sympathy; 
as diseases of other parts, and those which in distinction to well 
defined and limited affections we call general, are capable of 
affecting the teeth, it might be apparent, if we had no particular 
facts in evidence, that the morbid condition of the teeth may pro- 
duce corresponding evils in other parts, and may even involve 
the whole system in troubled and morbid action. 

It might also be evident that severe and long continued pain, 
located in the immediate vicinity of the brain, and in parts 
little accessible to soothing appliances, cannot be less dangerous 
to health than pain in other organs situated at greater distance 
from the nervous centres and more easy of access. 

It might also be perceived that sensitive organs, in imme- 
diate contact with the great lining membrane of the thoracic 
and abdominal cavities, and intimately connected with it by 
function, cannot be less capable of propagating disorder to it 
than parts located far from it, and having no immediate rela- 
tion to it. 

Yet natural as these inferences seem to be, they have been, 
14 



150 MOEBID EFFECTS OF THE TEETH, ETC. 

until lately, almost entirely overlooked, and even now the medical 
profession are by no means awake to the facts and the importance 
of the morbid relation actually existing between the teeth and 
other parts. 

It is exceedingly uncommon to hear that a physician, in search- 
ing for obscure causes of protracted ill-health, has paid any atten- 
tion to the state of the teeth, though often their terribly diseased 
condition cannot escape involuntary recognition by more of his 
senses than one. The matter is never alluded to in lectures 
delivered to medical classes, and, in fact, is hardly recognized at 
all as a subject for pathological or hygienic consideration. 

Within a few years, however, several writers upon dentistry 
have urged the medical profession to turn their attention to the 
diseased conditions of the teeth in connection with other dis- 
orders, and they have supported their appeals with such an array 
of well observed and clearly narrated cases as must impress the 
mind of all reflecting readers with the fact of the morbid rela- 
tions in question. 

Unfortunately, these writings are not read by the general 
practitioner, and it is to be feared that a long time must elapse 
before physicians become properly informed upon this subject. 
In the meantime it is the more important that every dentist be 
able to perceive these sympathetic conditions and call the atten- 
tion of the patient and physician to them. 

The teeth, while in a physiological condition, are capable of 
inducing great local distress, and constitutional disorder even of 
a fatal kind. During their evolution and passage through the 
gum, the pressure even of a sound tooth upon a sound gum may 
be attended by irregular phenomena of the most alarming kind : 
it would be strange indeed if the action of a diseased tooth upon 
the diseased gum should be attended with no evil consequences. 
That the process of dentition happens in infancy, causes cer- 
tainly a modification of effect in accordance with the peculiari- 
ties of the infantile constitution ; but, the action of morbid teeth 
upon the less mobile nerves of the adult may be as certain, 
though less rapid and ostentatious. 

The question, however, like other medical questions, is one of 
fact, not of inference. And we would leave the truth to be 
deduced from a fair examination of subjected cases. 



CHAPTER XIL 

MORBID EFFECTS OF FIRST DENTITION. 

Dentition is not, in itself, a morbid process, but a healthy- 
physiological act. It would be strange, therefore, if it neces- 
sarily involved disorder of function and serious consequences to 
the subject. 

The truth is, that when naturally performed, under the favor- 
able circumstances of sound constitution and good health on the 
part of the child, the cutting of the teeth is performed without 
pain or any collateral evil, these organs appearing in their place, 
without any previous unpleasant sensations to attract attention to 
their progress through the gum. It is thus that the domestic 
animals perform dentition, and many children complete theirs 
with no more perceptible inconvenience. 

More generally, however, the child experiences, at least with 
some of its teeth, more or less suffering of a local kind, and in 
many cases the pain is attended by sympathetic irritation of a 
grave and not unfrequently of a fatal character. 

It is important to know that, however large may be the pro- 
portion of painful, in comparison with natural dentition, the former 
are nevertheless to be regarded as accidental modifications of the 
regular and healthy process. Starting with this knowledge, we 
will, of course, be led to enquire into the causes, so general and 
so potent, which effect the changes in question, and to devise 
means and management most proper for escaping or annulling 
them. 

Does painful dentition depend upon the pressure exercised by 
the tooth upon the gums ? 

If it did, all children would experience suffering and more or 
less collateral morbid effects. For although the difference of 
natural sensibility in different children would occasion differences 
in the degree of trouble arising from this cause, yet this compara- 



152 MORBID EFFECTS OF FIRST DENTITION. 

tive sensitiveness, being merely natural and healthy, could not 
account for the extreme contrasts exhibited between easy and 
simple, and complicated and dangerous dentition. 

Nor is it all likely that extreme sensibility would escape mor- 
bid manifestation during the rapid evolution of infantile life, until 
awakened from its passivity by the evolution of organs, them- 
selves not sensitive, (in their healthy state,) passing through 
structures not by any means remarkable for this quality, and per- 
forming their eruption so gradually as to make no sudden de- 
mands upon the nervous and vascular system, so as to disturb the 
equilibrium of nervous and vascular distribution. 

Nor is it consistent with the facts observed in the history of 
dentition that the cause of the suffering is the pressure of the 
fangs of the teeth upon the periosteum of the alveoli. Those 
who adopt this explanation have not considered that the shooting 
of the teeth, characterized by the enlargement of the alveolar 
walls, and the distension of the gums occasioned by the forma- 
tion of the body or of the crown of the teeth is an epoch often 
more dangerous than that of the organization of the roots ; which 
besides would do much more harm in compressing and binding 
the soft and pulpy part of the tooth than the serous membrane, 
which performs the function of a periosteum and lines the interior 
of the gum and proper cavity of the teeth* 

The truth seems to be, that a great number of children are 
born into the world so feebly or disproportionably constituted 
that they are not capable of maturing. Most of these necessarily 
perish during childhood, by some of the many forms of disease 
common to that period. Many others, though born with suf- 
ficient vigor, are reduced by bad diet and defective management 
to a condition which readily yields to irregular or morbid agents. 

A child may be very feebly organized, and yet may appear for 
a time plump and healthy, but when the vital powers come to be 
tested either by accidental or physiological demands upon its 
energies, the natural feebleness is ascertained by the development 
of various morbid phenomena indicating the particular location 
and kind of disability. 

* Baumes on First Dentition. 



MORBID EFFECTS OF FIRST DENTITION. 153 

Again, children born healthy are often subjected to privations 
or to injudicious diet and regimen which rapidly alter their fluids 
and tissues, and lay the foundation for serious accidents. 

Dentition demands a certain amount of constitutional energy to 
accomplish it. The rapid development of any organ does this. 
The changes which take place at puberty, and the evil conse- 
quences, to the feeble, of the developments then completed, are 
illustrative of this fact. This demand is the severest test of 
functional and organic completeness in the child, and many will 
not bear it. • 

The development of the teeth determines an unusual flow of 
blood to the head. This happens at a time when the brain is 
proportionately large, and undergoing rapid evolution. Indepen- 
dently of dentition, this period of life is attended by a strong 
tendency to cerebral affections, and to pulmonary and abdominal 
complications. The nervous and vascular systems are, in the 
child of this age, remarkably active. The several organs have 
to perform not only their functions and the preservation of their 
entireness, but also rapid growth. Animal life is therefore ex- 
alted with all its qualities. Among these are sensibility and 
sympathy : the capacity to be impressed and to propagate im- 
pression. Hence a slight cause may produce great local or con- 
stitutional effect, and disease of any kind may induce sympathetic 
or constitutional disorder apparently much out of proportion to 
its own intensity or importance. 

In the older child the relation of secondary to primary affec- 
tions is more equable, and the second dentition is performed 
without the occurrence of those serious constitutional affections 
Which so frequently attend the first. 

Any unnatural obstacle or impediment to the eruption of the 
first teeth, will tend very materially to augment the probability of 
morbid consequences. A disproportion between the teeth and the 
jaw, or the unusual hardness and impenetrability of the gum, 
are of this nature, and sometimes provoke local and sympathetic 
disturbance. 

The appearance of several teeth at once may make a larger 
demand upon the system than it can readily meet, and hence cause 
embarrassment, or if their dentition be painful, the amount of 
14* 



154 MORBID EFFECTS OF FIRST DENTITION. 

suffering may be too great for the sensitive and sympathetic na- 
ture of the child, especially if it be constitutionally feeble. 

The natural symptoms of healthy dentition, are not remarka- 
ble. An increased flow of saliva is usually noticed, though this 
perhaps, is not as certainly the consequence of dentition as is 
generally supposed. The mouth of infants is generally well 
supplied with fluids, which, there being no teeth to prevent it, 
will escape more or less from the mouth. The child also carries 
its fingers to the mouth more frequently, and seems pleased to 
press a resisting substance between its gums. Gentle friction of 
the gum also seems to be agreeable. The gums are noticed to 
be hot, and the child takes the breast frequently. The bowels 
are generally looser than usual, and the child ordinarily mani- 
fests some little restlessnes and sleeps less profoundly than pre- 
viously. 

These symptoms precede the eruption of the teeth by several 
weeks, and seem to depend upon the rapid ossification and 
growth of the teeth. After a few days, they often subside, to be 
renewed when the teeth are pressing forward and about to pene- 
trate the gum. 

It is common to alleviate these little inconveniences, by giving 
the child a coral, crust of bread, or other hard substance, to 
press upon with its gums. 

Nature is generally a very correct guide as to her own wants, 
and as it is natural thus to allay the sensation of the gums at this 
period it must be right. A priori, however, we might have 
feared that the continual pressure would condense and harden the 
gum and make it more impenetrable. 

Inasmuch as nature has not indicated the precise degree of 
resistance proper for the purpose, it would be well to use sub- 
stances which do not possess this quality in an unnecessary 
degree. 

The French use a stick of marsh mallows, or liquorice root 
dipped in honey, or a sweetened decoction of barley — the Ger- 
mans, a small bag filled with sugar and spices. It is doubtful, 
however, whether the success of this invention for quieting the 
child may not induce the nurse or mother to neglect it, and 
withhold the breast which it would take eagerly and frequently. 
Nothing so soothes the infant as the frequent lubrication of 



MORBID EFFECTS OF FIRST DENTITION. 155 

the mouth with the mother's milk and where nothing in the state 
of the mother's health or the condition of her breast forbids this 
indulgence, it is cruel and unnatural to deny it. It may be, too, 
that the constant use of sweet and condimental substances would 
disorder the stomach of the child: an accident to be studiously 
avoided during teething. 

The bowels are generally loose during dentition, and even 
when the purging is very frequent we must not consider it ex- 
cessive while the child nurses freely, and especially while it 
does not emaciate. 

Costiveness is much more to be feared under such circum- 
stances than purging. It is unnatural, and unless overcome by 
proper treatment will result in irritations, local, and perhaps 
sympathetic, which may not easily be remedied. 

It is always important to restrict a teething child to proper 
aliment. The bowels may very readily be irritated, and the 
system is so liable to violent excitement at this time that all irri- 
tation should be dreaded, especially irritation of the abdomen, 
for this is the most important part of a child, being the centre 
of the very active processes of nutrition and augmentation every 
where going on. This is no time to try experiments upon the 
stomach. Nutritious and easily digested food, and that which is 
tree from acidity, is to be given, and in such quantities as the 
child is willing to take. Unless, indeed, it has been habitually 
over-crammed and taught to eat an unnatural quantity. 

When the mother has milk, this is, of course, the best food for 
the infant, but it will generally happen that the child will require 
more nourishment than it can obtain from this source. 

In selecting food for it, regard must be had to the condition of 
the child. If delicate and thin, animal food will often be indis- 
pensable. Beef, mutton, and occasionally a little salt meat may 
be given with advantage. Young meats are gelatinous and less 
digestible and should be avoided. 

If the child, on the contrary, be too fat, if it has been over- 
crammed with milk until it presents an appearance similar to 
that of the show calves, stuffed and swollen for exhibition at a 
fair, it should have diet of a far less nutritious kind. Farinaceous 
articles well diluted with water will be more suitable. 



156 MORBID EFFECTS OF FIRST DENTITION. 

Milk, if fresh and sweet, generally agrees well with children ; 
but the milk of the cow is more nutritious than that of the mo- 
ther, and should be diluted. Cream freely diluted with water 
generally agrees better than milk. 

It is common among the rich to thicken the child's milk with 
arrow root, Ions les mois, or other concentrated farinaceous food. 
The consequence generally is that the parents are enabled to 
rejoice over fat babies, and soon to sorrow over sick ones. In- 
stead of making the milk of the cow more nutritious, it should be 
rendered less so than natural. It is rarely that articles of this 
kind, even when they are what they are represented to be, are fit 
for children. But this is rarely the case. Most of the arrow 
root, &c. of the shops is potato starch.* 

Some parents are in the habit of refusing children flesh of all 
kinds, and indulging them freely in milk and potatoes. The 
result generally is to fatten the children excessively, without 
providing them with a proportionate amount of muscular fibre. 

The child should have as much exercise in the open air as the 
circumstances of the parent will admit. All kinds of exercise 
seem to do it good. It is seldom fatigued even by very long 
rides, and rarely fails to acknowledge in its altered appearance 
the good effect of even an hour's exercise in the fields. 

Frequent bathing is of great use to children of all ages, but 
even this means requires to be administered with judgment. 
The cold bath is a powerful remedy, and cannot be used with 
equal safety and advantage upon all children. Those who are 
ruddy and robust will bear it well ; while others who are pallid 
and of cold skins may suffer serious injury from it. If after the 
bath the child shivers for a considerable time, and remains cool, 
and if it contracts a dread of the water, the temperature should be 
elevated to meet the condition of its sensibilities. 

Of course, in cold weather, the water should always be warmed 
in proportion to the necessities of the case. 

When dentition becomes complicated with morbid conditions, 
directly or indirectly connected with it, the management of it 
requires far more care and skill. The local symptoms are to be 

* If the milk require the addition of any farinaceous substance, I prefer 
rice flour. 



MORBID EFFECTS OF FIRST DENTITION. 157 

allayed, serious symptomatic affections are- to be relieved, and 
the strength of the child to be supported through a tedious pro- 
cess, in which the powers of the system are taxed to their utmost 
capacity. A single mistake here will often prove fatal, and it is 
easy under such circumstances to make mistakes. 

The diseases of dentition are local, those which affect the 
teeth, gums and mouth — or sympathetic, those which manifest 
themselves in other organs. 

The local diseases of dentition are, first, inflammation of the 
gums. These are swollen, hot, redder than common and very 
sensitive. The child will not permit them to be touched, and 
incessantly craves the breast, or cold liquids. The condition of 
the gum is almost always attended with more or less fever and 
irritation of the intestinal canal. There is also an evident deter- 
mination of blood to the head. The face is flushed, the head hot, 
the eyes red and watery, the flow of saliva profuse, and some- 
times the salivary glands are swollen and tender. Aphthous exu- 
dations are often noticed, and it is said, though this must be very 
uncommon, that abscesses sometimes occur at the root of the 
tongue. 

The fever is generally ardent, and increases and subsides 
with remarkable suddenness. The thirst attending it is very 
great, and a strong tendency to irregular muscular contractions 
or convulsion is generally observed. The sleep of the child is 
uneasy and frequently interrupted. It frequently starts and 
screams, and when awake is usually fretful and stupid by turns. 

These symptoms are often very suddenly and effectually 
allayed by freely incising the gum and capsule down to the tooth 
or teeth, and liberating them from their investments. This ex- 
pedient is generally resorted to whenever the gum is elevated 
and distended , sometimes, however, it is of no avail, either be- 
cause it is not effectually done, or because the symptoms to be 
relieved do not in fact depend upon the mere mechanical pres- 
sure. 

The French writers make a formidable matter of this little 
operation; and indeed, as practised by some of them, it is no 
trifle, for they make a crucial incision upon the tooth and dis- 
sect up the flaps of the gum, or else, with a bistony, completely 
cut off the top of the gum. 



158 MORBID EFFECTS OF FIRST DENTITION. 

There is no necessity for such painful and protracted opera- 
tions ; a free incision, until the lancet grates upon the tooth, is 
all that is necessary for the incisors; and when the double teeth 
are in question, a cross incision may be added. 

The lancet should be carried down to the tooth, or else no 
good will be done. 

The bleeding which results is trifling and salutary; tending to 
relieve the inflamed and swollen gum. 

It has been objected to this operation, that unless the tooth 
should be very near the surface, the incision would heal and the 
cicatrix would offer more resistance than the original structure 
of the gum. 

The fact is, however, that if such a cicatrix should occur, and 
the symptoms return, it would be very easy to divide the gum 
again ; moreover, a cicatrix is always a feeble tissue, which is 
far less resistant than the natural part whose loss it represents. 

Conjointly with the use of the gum-lancet, attention must be 
paid to the bowels of the child. If it be costive, the torpor of 
the bowels must be relieved by the administration of proper 
purgatives. Of these, calomel is for several reasons by far the 
most useful, and is equally safe, for occasional administration, 
with the most innocent of the class. 

In these conditions the abdominal secretions are always 
vicious, and we have no means so powerful as calomel for the 
restoration of impeded or altered secerning function. To a 
child of a year old, four, and to one of two years, eight grains 
should be given at a single dose ; and, if necessary, its cathartic 
effect insured by the subsequent administration of castor oil or 
magnesia. 

Small doses of calomel are ineffectual, and, if frequently re- 
peated, are dangerous. 

Should the bowels be too loose, and the passages thin and 
white, the same medicine similarly administered, or joined to a 
little rhubarb or chalk, will generally check the diarrhoea. 

In these cases, as where constipation exists, the fault seems to 
be in the deficit or altered secretion of the liver, which calomel 
restores. 

The fever will generally abate in proportion as the bowels are 
put right. Should it continue ardent, however, and especially if 



MORBID EFFECTS OF FIRST DENTITION. 159 

the cerebral plethora should increase or remain unabated, a few 
leeches behind the ears will often prove serviceable. 

The cold bath, or sponging with cold water, will also allay 
the fever and restlessness. The warm bath may sometimes be 
preferable, and will be equally serviceable. Above all, country 
air, and exercise out of doors, are the best means of combating 
the disorders of dentition. 

" Very different," says Mr. Jay,* " was the practice of our 
forefathers, who, misled by the fanciful doctrine of signatures, 
were in the habit of applying to the gums specific ointments 
made of the brains of hares, or of the combs of cocks, which, as 
old Hartman would have us believe, ' cause the production of 
teeth without difficulty, and free from accidents."' 

It is questionable Whether we have much right to laugh at 
the metaphysical medicine of our ancestors : certainly our poster- 
ity will find abundant occasion to ridicule our own. 

We have yet to learn that any ancient theory or practice of 
cure was more utterly absurd than Homoeopathy or the cold 
water treatment. The doctrine of signatures is quite as philo- 
sophical as mesmerism, and the combs of cocks and brains of 
hares are certainly as efficacious as Hahneman's dilutions. 

Among the local diseases of complicated dentition we must 
enumerate caries of the tooth and abscess of the gum. When 
from any cause, local or constitutional, caries of the tooth takes 
place, it engenders inflammation of the periosteum, which 
soon extends to the gum. This becomes painful, swollen and 
tender ; an effusion of fluid takes place between the fang and its 
investing membrane, which thus becomes a sort of cyst or sac. 
Finally pus is formed, an abscess appears, and the matter is 
voided, either by a spontaneous or artificial opening. 

The continuance of the carious tooth as an irritant will, of 
course, prevent the proper healing of the ulcer, and the fungus, 
so common in carious ulcers, will shoot up. 

" In other cases the pressure of the abscess having produced 
absorption of a portion of the alveolar process at its lower part, 
it effuses its contents through the aperture thus formed, and the 
matter insinuates itself along the surface of the lower jaw, and 

* Cyclop, of Prac- Med., Art. Dentition. 



160 MORBID EFFECTS OF FIRST DENTITION. 

forms an internal tumor near its base. This tumor is at first hard 
and discolored, but in the course of time it ultimately inflames, 
and bursting or being opened, leaves a puckering in the integu- 
ment, which, adhering to the bone, remains a permanent blem- 
ish. When the diseased tooth, which is the cause of the mis- 
chief, is removed before external redness takes place, the tumor 
ultimately retires, and leaves the skin unblemished."* 

A spongy condition of the gums, in which they bleed freely at 
the slightest touch, is sometimes observed in dentition. Ulcera- 
tion sometimes attends this condition. Weakened digestion and 
consequent imperfect preparation of chyle and insufficient nutri- 
tion, may be considered the cause of this affection. 

Treatment. — Inflammation of the gum may be very much 
abated by the application of a leech to it. In order to do this with 
facility, a thread may be passed by a needle through the ex- 
tremity of the animal, and it then may be enclosed in a glass tube. 
When the inflammation has subsided, the carious tooth should 
be extracted. 

Should an abscess occur from a similar cause, extraction must 
also be resorted to. 

Sponginess and ulceration of the gums, depending upon a de- 
praved digestion, must be met by such means as will restore the 
alimentary canal to the regular and complete performance of its 
functions. 

Mild astringent lotions, such as myrrhine and aluminous solu- 
tions, may be simultaneously employed. 

* Coleys' Diseases of Children. 



CHAPTER XIII. 

SYMPATHETIC DISEASES OF DENTITION. 

A vast number of diseases have been described by different 
authors, as the results of dentition. The recapitulation of them 
would show a crowded list of formidable complaints, from which 
it would seem that no child could escape. Dentition appears in 
this exhibition as the Pandora's box from which all manner of 
evils are successively let loose to worry and destroy the devoted 
infant. Without pretending to enumerate the forms of disorder 
attributed to teething, we offer the following as a specimen: 
Vomiting, anorexia, diarrhoea, cholera, costiveness, increased or 
diminished urine, urethral or vaginal discharge, with painful 
micturition ; dry cough, dyspnoea, catarrh, pneumonia, spasmo- 
dic affections of the face, limbs, glottis, &c., insomnia, agitation, 
and fright on awaking; epilepsy, somnolence, stertor, coma, tran- 
sient palsy of the arms and legs, ophthalmia, hydrocephalus, ma- 
rasmus, eruptions, especially about the head and face, swelling of 
the hands and feet, enlargement of the cervical, femoral and me- 
senteric glands, and other scrofulous affections. 

Although any of these disorders may, and all of them do 
occur during dentition, it does not by any means follow that 
teething is the cause of them. The mucous membranes of chil- 
dren are very liable to inflammatory affections, and their brain 
is very liable to sympathize with these and other disorders. 
Moreover, the process of dentition would certainly afford an awk- 
ward complication to any of these forms of disorder occurring 
simultaneously with it, or provoked by accident during the pro- 
gress of teething. No doubt also, dentition itself, especially if 
obstructed, or otherwise irregular or morbid, may become the 
exciting cause of any disorder to which the child may at the 
time happen to be most prone. 
15 



162 SYMPATHETIC DISEASES OF DENTITION. 

Should inflammatory affections of mucous membranes occur 
during dentition, the treatment should be regulated by the nature 
of the particular case, and the judgment of the physician. It 
would always be well, however, to examine the gums carefully, 
and to incise them freely if they be at all swollen. This can 
do no harm, and sometimes will result very happily. 

Very often, perhaps most frequently, the mucous affections are 
not inflammatory, but consist in a kind of morbidly increased sensi- 
bility, which we call irritation. The irritability of the stomach, 
the vomiting and purging are frequently of this kind, and would 
only be aggravated by antiphlogistic treatment. 

Proper purgatives, especially calomel : proper food, and suf- 
ficient exercise will be found to accomplish all or nearly all that 
art can do for the relief of such conditions. 

The cough which accompanies dentition is also due to the 
irritability of the mucous membrane, and need no special treat- 
ment. 

The inexperienced practitioner must be careful, however, not 
to confound this condition with proper catarrh or pneumonia. 
Children are liable to severe pulmonary disorders, which require 
the most prompt and vigorous treatment, and which it would 
always be serious and often fatal to neglect. 

The febrile disturbance, the quick, short respiration, the dis- 
tended nostril, and the indescribable, yet intelligible appearance 
of the little patient, will render mistake entirely unnecessary. 

The most serious complication of dentition is undoubtedly 
a gastro intestinal disorder, which has acquired the name of 
Cholera Infantum. 

This disease occurs only in hot weather, and is almost peculiar 
to cities. Occasional cases of it, however, occurring in warm, 
unsheltered places in the country, are sufficient to show that its 
urban character is dependent simply upon the heat of cities, 
which especially at night is very much greater than is experi- 
enced in rural situations, unless very unfavorably circumstanced. 

This disease seems closely connected with dentition, for al- 
though very young infants may be attacked by it, they are by 
no means so liable as those who have completed their first year. 
Hence the familiar danger of the child's " second summer." 



SYMPATHETIC DISEASES OF DENTITION. 163 

The disorder usually commences by purging ; frequently as 
the immediate consequence of some indigestible substance taken 
into the stomach, but often without any known exciting cause. 
The matters passed at first are light green — presenting somewhat 
the appearance of chopped grass, and gradually becoming paler 
until they are of an extremely pale yellow or absolutely white. 
Vomiting, especially after swallowing liquids, generally attends 
the diarrhoea, and commonly fever of a fickle fluctuating charac- 
ter also occurs. 

The child emaciates very rapidly, and in a few weeks or days 
will be reduced to a mere skeleton, and be too feeble to stand 
alone. The brain and nervous system become torpid, the muscles 
relaxed, the child somnolent and stupid, and death, from cerebral 
congestion or convulsions, closes the scene, 
i The disease is sometimes acute and rapid in its development 
and progress, at other times chronic. The only medicinal agent 
which is uniformly beneficial in this disease is calomel. The 
nature of the alvine discharges evinces a deficiency or entire 
absence of bilious matter. A full purgative dose of calomel 
rarely fails to restore this secretion, and all the symptoms are 
alleviated by it. 

From the fact that this medicine can be given in small bulk, 
that it is almost tasteless, and that it will remain in the stomach 
which rejects all other drugs, it is peculiarly adapted to the con- 
dition in question. As this adaptation makes it the most availa- 
ble, it is exceedingly fortunate that its medical qualities make it 
by far the most efficient of remedies in this disease. 

Some writers recommend it to be given in small doses, fre- 
quently repeated, but while there is no advantage to be gained by 
this procedure, there is risk incurred of mercurializing the child ; 
which would generally be fatal to it. It is true that this rarely 
occurs; but some children have a peculiar constitutional sucepti- 
bility to mercurial action, and it is better to risk nothing unne- 
cessarily inr this respect. 

The dose which experience leads me to employ, is from 
five to ten grains, according to the age of the child and the con- 
dition of its sensibility. It may be repeated several times within 
a week or less, if necessary. 



164 SYMPATHETIC DISEASES OF DENTITION. 

Alkaline medicines, soda, potassa, magnesia and chalk, are also 
useful in neutralizing acid, and, perhaps, also in correcting the 
disordered condition of the mucous membranes. 

A cautious, yet bold use of opium, will often render service 
which no other treatment will afford. It quiets the stomach, 
soothes irritation, checks the diarrhoea, and gives refreshing 
sleep. 

The great difficulty in the treatment of this disease arises 
from the fact that it is the result of causes which continue to act: 
so that the disorder is constantly reproduced. 

These causes are heat and dentition ; and it is often impossible 
to cure the child while the causes continue to act. 

In large well ventilated rooms it is often possible, even in 
cities, to procure for the child a temperature which is salutary ; 
but even under these circumstances it is not always possible to 
do so. When, therefore, the little patient is the child of poverty, 
imprisoned in the small room of a small house, shut up in a court 
or alley, it is almost impossible to rescue it from death. 

The most certain of all remedies is to take the child to the 
country. There proper medical treatment will rarely, or never, 
fail to cure the disease. Children in apparently the last degree 
of prostration are sometimes revived as by miracle, by the cool 
air of the country. 

But when we say country, we do not mean a hot room near 
the roof of an unshaded tavern fronting on a turnpike road, where 
numbers of sick children are shut up together, in a temperature 
perhaps higher than that of the spacious city mansions from which 
they have been hastily removed. Shade and green grass are 
essential. There must be no bare surface to reflect the heat, 
and there must be shade where the child may be exercised, and 
where it may be conveyed in the middle of the day, when coun- 
try houses are as warm, and often, from their size and construc- 
tion, warmer than city dwellings. 

Convulsions very frequently occur during dentition. They 
are of an epileptic character. The symptoms are a fixed stare 
and often distortion of the eyes, insensibility and frequent irregu- 
lar contraction and expansion of the muscles, generally of the 



SYMPATHETIC DISEASES OF DENTITION. 165 

limbs and face. The jaws are firmly clenched, and the saliva is 
ejected in froth from the lips. 

This is a very frightful and generally very alarming affection, 
though not very often fatal. 

Convulsions during dentition may be excited by several causes. 
The first and the most common is the eating of crude and indi- 
gestible matters ; secondly, fever ; and thirdly, the irritation of 
the teeth themselves : often two, and sometimes all three of these 
causes act together. 

The convulsion generally passes off in a few minutes, but 
another will occur unless the cause be removed. Sometimes it 
will continue with little or no mitigation for hours, and some- 
times it continues until the death of the patient. In order to 
relieve the spasms, it is generally sufficient to put the extremi- 
ties in warm water and pour cold water on the head : if this do 
not speedily accomplish the end, more active means must be 
used, and such as look to the removal of the cause. 

If spontaneously, or by use of the bath, the convulsion sub- 
sides, we should carefully enquire into the cause of it. If the 
child has eaten anything, it should be immediately vomited, and 
indeed this can rarely be amiss, for it is often impossible to elicit 
the necessary information, until the presence of the ejected 
matters exhibits the cause of irritation. 

If the child have fever, it should be bled, in order to relieve 
the brain, which is suffering from the rapid circulation of blood 
through it. This may be done either by the lancet or by 
leeches. 

If the gum be swollen and tense, and the child seems to be 
suffering from this cause, a free incision will often relieve the 
tendency to spasm, by allaying the local, and with it the cerebral 
irritation. 

Finally, if the child be costive, its bowels should be imme- 
diately opened by injection, and subsequently by a purgative dose 
of calomel. 

Dr. Underwood describes a peculiar swelling of the hands and 
feet as a casual attendant upon dentition. He considered it, 
however, as rather beneficial than otherwise, as it ceased spon- 
taneously with the appearance of the teeth. 



166 SYMPATHETIC DISEASES OF DENTITION. 

Cutaneous eruptions frequently occur during dentition, but 
they are of little consequence, as they spontaneously disappear, 
and, in some instances, may be considered as a salutary diversion 
made by nature for the relief of the brain. Sometimes, how- 
ever, they are so disagreeable, that some efforts are demanded 
for their relief. Most, or perhaps all of them, occur indepen- 
dently of dentition, and as a description of them would be tedious 
and, without plates, unsatisfactory, and as they are all fully 
described in works specially upon this subject, it will only be 
necessary to name them here ; so that the student may seek fur- 
ther information from writers upon cutaneous disease. 

The principal varieties are, an erythematous efflorescence 
behind the ears, called, in medical language, intertrigo : crusta 
lactea ; the several varieties of strophulus ; small phlyctenae, or 
blisters, and evanescent red spots. 

Although these eruptions occur frequently during dentition, 
they are by no means peculiar to this period, and it is difficult to 
show that they are necessarily connected with the cutting of the 
teeth. 

Intertrigo. 

This is a kind of erythemic or superficial inflammation of 
the skin, generally attended with some exudation of a semi- 
purulent matter, occurring behind the ears. When the two 
excoriated surfaces rub upon each other, the result is frequently 
a very ugly superficial ulcer. The disease can be readily cured 
by the use of absorbent or " drying" powders. All moist appli- 
cations do harm. A most valuable prescription for this and 
similar conditions of the skin is a powder composed of two 
parts of lapis calaminaris and one part of calomel rubbed 
together in a mortar. This is to be freely dusted upon the sore 
by means of a little raw cotton, several times a day. It will 
rarely fail of success. 

There is an opinion very prevalent that it is hazardous to 
dry up these eruptions, but there is no ground for this sup- 
position. 



SYMPATHETIC DISEASES OF DENTITION. 167 

Crusta Lactea or Milk Crust, (Porrigo Larvalis.) 

This eruption appears with" white vesicles, speedily passing 
into dark-colored scabs, itching and ichorous, and frequently 
covering a large part of the face, head, and sometimes other 
parts. 

The eruption is very ugly and unpleasant, but is rarely inju- 
rious to the child. The little patient is generally plump and 
hearty. Indeed, the disease seems rather to depend upon a ple- 
thoric state, than upon any morbid condition of an important na- 
ture. The teething is not impeded by it. 

Crusta Lactea is often obstinate and of some months' duration. 
The only serious attendant upon the disease is the itching, which 
is sometimes so annoying to the child as to cause it to fall away, 
and become sallow, &c. 

No treatment is required, or, rather, none does it much good. 
The bowels should be kept free, and the itching allayed by warm 
bathing, lotions of weak spirit and water, and solutions of Sul. 
Zinc. 

Where there is much discharge from beneath the scabs, the 
drying powder already mentioned is a good application. As a 
general rule, the less we do to cure this affection the better. 
Time will certainly restore the child its natural skin; medicine 
might, and if persevered in, would destroy its appetite, tease its 
stomach, enfeeble its health, and, after all, produce no effect 
upon the eruption, except, perhaps, to make it worse. 

Strophulus, Tooth Rash, Red Gum. 

This is an eruption very common to nursing children. It 
consists of red or white and itchy papulae evolved upon the face 
and lower limbs, disappearing and returning, and ending generally 
in the throwing off of a kind of powdery desquamation. 

The papula; present differences in size and appearance, which 
have given origin to different designations. When vividly red, 
prominent, scattered over the cheeks, face, arms, and dorsal 
aspect of the hands, and intermingled with erythematous patches 
of varying extent, it is called Strophulus Intcrtinctus, (Rayer.) 



168 SYMPATHETIC DISEASES OF DENTITION. 

When the papulae are white," large, and without surrounding 
redness of the base, the affection is called Strophulus Candidus, 
(Willan.) 

When the papulas are very thick, smaller and confluent, Wil- 
lan calls it Strophulus Confertus ; and, finally, S. Volaticits, when 
it occurs in circular patches, or clusters, here and there, on the 
surface. All these forms of strophulus may affect the child at 
the same time. 

It is not by any means a serious affection, though it sometimes 
torments the child by the itching it causes. To allay this, we 
may use the cold or warm bath, purgatives, and cool dressing ; 
for the sufferings of the child may be very unnecessarily aggra- 
vated by warm clothing, especially at night. 

The disease spontaneously declines, in a few days or weeks, 
leaving behind it no traces of its previous existence. 

Phlyclence, are vesications or blisters of different sizes, resem- 
bling scalds or burns. They soon disappear, and require no spe- 
cial treatment. 

There are a number of rashes seen during dentition, which it 
is not necessary for us to describe particularly. Scrofulous 
children are subject, during dentition, to the lymphatic disorders 
peculiar to their constitution, such as is manifested by the 
swelling of the cervical, inguinal and mesenteric glands. 

The treatment of these, and kindred affections, must turn upon 
the means of invigoration previously referred to when consider- 
ing the constitutional vice upon which they depend. Proper 
nutriment, exercise, clothing, &.c, will do all that can be expect- 
ed from external agents. 

Second Dentition. 

The cutting of the second set of teeth is commonly accom- 
plished without inconvenience, either of a local or constitutional 
character, with the exception of the wisdom teeth, which being 
often crowded, not unfrequently occasion a great deal of suffer- 
ing, such as acute local pain, inflammation of the gums and adja- 
cent tissues, fever, violent headach, ophthalmia, &c. This 
suffering has often been mistaken for that accompanying other 



SYMPATHETIC DISEASES OF DENTITION. 169 

affections, such as neuralgia, intermittent fever, and rheumatism. 
Abscesses near the angle of the jaw may occur under these 
circumstances. 

Of course the treatment, under such circumstances, would be 
to liberate the impeded tooth by a free incision, or even, under 
certain conditions, to extract it. The inflammation of the 
soft parts must be combated, if necessary, by antiphlogistic 
means. 

Third Dentition. 

A number of well authenticated cases of partial and even com- 
plete dentition, occurring in very old persons, are recorded in 
the books. In one instance recorded in the Edinburgh Medi- 
cal Com., vol. iii. the subject of this late teething suffered very 
severely. 

The patient, in this instance, was sixty years old, and entirely 
toothless. At this time he experienced very severe pain in his 
gums and jaws, which at length amounted to excruciating tor- 
ture; but at the end of twenty-one days from the beginning of his 
sufferings, he was compensated by the appearance of a complete 
new set of teeth. 

With regard to the constitutional effects of this abnormal den- 
tition, Prof. Harris, who relates two cases of this kind as having 
occurred under his own observation, remarks : " It would seem 
that the efforts made by nature for the production of a third com- 
plete set of teeth, are usually so great, that they exhaust the 
remaining energies of the system ; for occurrences of this kind 
are generally soon followed by death." 



CHAPTER XIV. 

EFFECTS OF DISEASED TEETH AND GUMS UPON THE GENERAL 
HEALTH. 

That diseased conditions of the teeth and the structures ad- 
jacent to them, do exert a most pernicious influence upon the 
general health, is a fact as well established as any other medical 
observation ; yet the medical profession are, as yet, with very 
few exceptions, entirely unaware of it. 

We are not apprised that the subject is ever alluded to by 
lecturers on the practice of physic, when recapitulating to their 
classes the causes of functional disturbance and constitutional 
suffering; it is not noticed in the many text-books on practice; 
and, certainly, however frequently the physician may look into 
the mouths of his patients, it is very rarely that his comprehen- 
sive glance perceives any thing worthy of note in the decaying 
organs of mastication. 

It is full time that practitioners of medicine should perceive 
the importance of the teeth and of their diseases; but, until they 
do so, it is the more important that the dentist should be able to 
point out the causes of obscure disease, which the physician has 
in vain endeavored to discover, simply because he has sought for 
it every where but in the right place. 

It might be granted, a priori, that if physiological conditions 
of the teeth, owing to their peculiar position, association, and 
history, may exercise powerful influence upon the health of other 
organs, pathological conditions of these same teeth cannot be 
entirely harmless. 

Again, if we would examine the structure of a tooth, and 
perceive how completely its sensitive part is enclosed in an un- 
yielding bony case, we might readily infer from the consequences 
of compression in other parts, that the swollen and inflamed pulp, 
&c., would be exceedingly painful. If, too, we would regard 



EFFECTS OF DISEASED TEETH AND GUMS. 171 

the close connection existing between the teeth, the rapidity with 
which the flash of sympathetic pain darts along the nervous cords 
which vitalize them, and the intolerable and protracted suffering 
which ensues, upon even trifling irritation of these sensitive fila- 
ments, and remember that pain itself is fully capable of derang- 
ing the whole economy, and inducing serious and fatal disorder, 
we might, without the aid of much reflection, adopt the very ra- 
tional conclusion that the diseases of the teeth must be of con- 
siderable consequence to the entire organization. We might, 
also, with similar propriety, conclude that the teeth were not 
made merely for ornament, and that mastication and insalivation 
are something more than mere forms of introduction to the sto- 
mach ; that they are important to digestion, which is important 
to the entireness of organs and the performance of function, and 
that if mastication, and the insalivation accompanying it, be im- 
perfectly performed, some corresponding imperfection of diges- 
tion must result. We might also infer, from the known con- 
sequences of long-continued morbid influences, however unim- 
portant in their immediate action, that disturbance of digestion, 
constantly repeated, must, in time, develope evils of a serious 
character. 

The old pathological maxim, "ubi irritatio ibi fluxus,"* is 
fraught with a valuable lesson to the medical practitioner. It is 
true that the nervous, and to a certain degree, even the vascular 
forces hurry to the part which throws out the signal of distress, 
and all the floating energies of the system are directed to the re- 
lief of the suffering. If it can be readily accomplished, the 
equilibrium of the system is soon restored and no perceptible in- 
convenience results. But if from the impracticable nature of the 
tissue or organ affected, but little relief can be given, and if the 
efforts of nature to accomplish cure or removal of the part, end 
only in accumulating about it an uncommon amount of sensibility, 
increasing the irritation and demanding yet more of constitutional 
effort to combat it, the consequence must be such a diversion of 
nervous influences from other parts as to weaken their force of 
action, and to embarrass their functions. 

• "Where there is irritation, to thai pari will l>o iru> flow." 



172 EFFECTS OF DISEASED TEETH AND GUMS. 

In short, it is easy to understand that when the first movement 
towards constitutional derangement has been made, if the cause 
continue to act, each accession of morbid condition must aggra- 
vate and extend the evil, and hence it is that causes in them- 
selves very slight may, if long continued, from the influence of 
sympathy and the accident of relations, induce morbid conditions 
of the most serious character. 

The remarks of Mr. Koecker upon this point are so sensible 
and so well expressed, that no apology will be necessary for in- 
troducing them here at some length. 

Mr. Koecker observes that, " to form a more distinct concep- 
tion of the very powerful morbific influence which the diseases 
of the teeth and their contiguous parts must unavoidably pro- 
duce upon the general constitution, it is necessary to consider the 
peculiarity of the structure and functions of these parts. 

" The extremely hard and dense structure of the bony parts of 
the teelh, and the great arterial activity and nervous irritability 
of their lining membranes, which can so powerfully, and for so 
long a time, defend the teeth against general local and morbid in- 
fluences, are also causes of their producing very extensive morbid 
effects upon the whole system. The functions of the teeth as 
well as of the gums, when in a healthy state, act as powerful 
stimuli towards their preservation, but when these parts are dis- 
eased or affected with disorder of any kind, they become con- 
stant causes of irritation upon them as well as upon the general 
health. The bony structure of the teeth, however, having in 
itself but little self-restoring power, and their peculiar func- 
tions being much less favorable to this natural process than those 
of any other part of the body, and the teeth and their gums, 
periostea and sockets, being altogether dependent upon each 
other, this power is much more constantly and in a much higher 
degree required, and seems to be much more exerted by these 
than by any other structures, and the more these powerful efforts 
are incapable of curing the dental diseases, and resisted in their 
efforts to remove their causes, the more active is the constitution 
in its attempts to resist the progress of such diseases, whilst at 
the same time a considerable portion of general health and 
strength is consumed in the struggle. 



EFFECTS OF DISEASED TEETH AND GUMS. 173 

" Diseases in the bony structure, and indeed of the teeth and 
gums generally, when yet in their incipient stage and without 
being influenced by any other causes than the local disorder 
itself, produce no greater constitutional effects than other local 
maladies; but with this difference, that their self-curative action 
is exerted in a proportion corresponding to the peculiar struc- 
ture, functions and relations of these parts, and therefore com- 
paratively much greater and longer continued than that produced 
by diseases of other parts or bones. In this state they proceed 
very slowly, and their morbid effects can only be detected by 
the most minute attention. 

" The genera] system, however, in the meantime being often 
disturbed, the caries will be found to proceed much faster to- 
wards the cavity of the teeth, and the inflammation of the gums to 
increase. In that event, any constitutional disorder is competent to 
aggravate the local one, whilst the latter, also, in its turn, greatly 
excites and augments the former. At this period it may be still 
taken as a general rule, that the morbid influences of general 
disease upon the dental maladies are more powerful than those 
of the teeth upon the general system. 

" The teeth having been deprived of their vitality by the de- 
struction of their lining membranes, are not only rendered use- 
less, but are converted into lifeless incumbrances upon the sys- 
tem, which produce, by their mechanical and chemical irritation, 
an action similar to that effected by gangrene or mortification in 
other bones, by means of which, nature attempts to throw off the 
dead part. 

" The parts surrounding such dead teeth, viz : gums, periostea, 
sockets and maxillary bones, are thus involved in serious disease, 
inflammation gradually extends over the whole of these parts, 
and a strong effort appears to be made to effect the expulsion of 
the decayed teeth, now become dead and offending bodies. But 
although nature might succeed in thus removing almost any other 
soft or hard part of the body of equal dimensions, in a few 
weeks or months, a space of from five to ten years, and some- 
times a much longer period is required for the removal, by the 
same natural power, of a dead tooth. 

"As long as the primary diseases are principally confined to the 



174 EFFECTS OF DISEASED TEETH AND GUMS. 

teeth themselves, and in these instances where they are the prox- 
imate local causes of diseases of the mouth without supposing the 
existence of many dead stumps of teeth, so long may we look for 
those acute symptoms and effects which have been stated, and see 
them change alternately from one form of disease into another, 
but after that period, or when the local maladies having origi- 
nally commenced in the gums, periostea, alveoli and maxillary 
bones, shall have extended to a certain degree, a total transition 
into a permanent chronic state of the disease takes place. 

" In such a state of disease nature seems exclusively and actively 
engaged by producing inflammation and suppuration in extricating 
the mouth from all the morbid causes effecting the diseased 
parts, such as dead roots and stumps, tartar, and teeth which are 
loose or irregularly situated. The sanative power of nature, 
being however, very rarely competent to effect such a cure, the 
various diseases of the gums, periostea, alveoli, and maxillary 
bones are exasperated, and for the most part terminate in a state 
of suppuration and mortification." * 

When the chronic condition here described has been fairly 
reached in the progress of disease, the sensibility of the parts is 
much diminished ; the gums and periostea are thickened and 
callous, and ihe continual discharge sufficiently depletes the ves- 
sels, to relieve them of the suffering incident to inflammatory 
engorgement. All resistance to devastation of the dental arch, 
seems to cease, and the parts are abandoned to rapid destruction. 
In the meantime the patient congratulates himself that his teeth 
have ceased to ache, and consequently gives himself no trouble 
about them. Inflammation, suppuration and caries now spread 
along the dental arch until every tooth is broken down and every 
root has become a permanent irritant, provoking a constant puru- 
lent discharge from the soft parts about it. 

The food is no longer chewed, and everything which passes 
through the mouth is mixed with a vitiated compound of saliva, 
mucous, pus and blood, which descends to the stomach to mingle 
with the gastric juice and deteriorate the quality of that most 
important fluid. 

* Koecker, Princ. Dental Surgery. 



EFFECTS OF DISEASED TEETH AND GUMS. 175 

The absorbents, too, are constantly at work, and the dissolved 
fragments of carious bone, &c, are constantly thrown into the 
current of the blood. 

The alveoli cannot escape the general ruin. Involved in the 
all-pervading inflammation, they also suppurate and break down, 
and not unfrequently the maxillary bones and the antrum are also 
involved in disease. 

Dyspeptic symptoms, marasmus, cough and other pectoral 
symptoms, violent neuralgic affections of the face, great nervous 
depression, hysterics or hypochondriasis, may be expected to 
attend such conditions of the teeth. 

The dyspepsia is easily accounted for. In the first place, the 
food is badly prepared for the stomach ; 2d, the fluids of the 
mouth, constantly trickling into the stomach, impair its tone and 
vitiate its solvent secretion ; and 3d, the continual demand made 
upon the system by the vain efforts which nature makes to cure 
the diseases of the teeth, and also by the frequent and severe 
pain, diminishes the nervous influence which the stomach re- 
ceives, and impairs its powers. 

Every one is aware that when the stomach is full, there takes 
place in that organ such a concentration of nervous energy as is 
sensibly felt by its loss, in other parts of the body. Hence the 
drowsiness and the indisposition to mental and physical effort 
experienced after a hearty meal. 

It is also well known that anything which attracts from the 
stomach this accumulated nervous power, impairs appetite and 
digestion. 

Extraordinary emotions, powerful intellectual efforts, venereal 
excesses, &c, all act in this way upon the digestive apparatus. 
Pain, also, wherever located, produces a similar effect, and the 
impairment from this cause will be important in proportion to 
the frequency and continuance of the suffering. 

In these several facts we have sufficient reasons for the indi- 
gestion which so frequently attends extensive diseases of the 
teeth. 

Marasmus, or gradual emaciation, is but a consequence of the 
insufficient nutrition attending dyspepsia. 

Cough and other pectoral symptoms, may result as the conse- 
quence of any prolonged irritation, especially if digestion be 



176 EFFECTS OF DISEASED TEETH AND GUMS. 

impaired. The mucous membrane, of the larynx, trachea and 
lungs sympathizing with similar structures and participating in 
the common defect of nutrition. 

Neuralgic affections of the face, head and neck are occasioned 
by the continual irritation of the extremities of the dental nerves 
and the propagation of it to the trunk and branches of the great 
fifth pair or trifacial nerve. 

Depression of spirits, hysterics and hypochondriasis result from 
continual nervous irritation, and the debility of nerve which 
results from long-continued over-action. Indigestion also is a 
powerful cause of the melancholy or hysterical condition so 
often observed in these cases. 

Epilepsy and other affections not enumerated above, sometimes 
occur as the result of dental irritation, as will be shown by the 
following cases narrated by Dr. Rush (Med. Repos. vol. 6, 285 :) 

Case 1. " Some time in the month of October, 1801," says 
Dr. Rush, " I attended Miss O. C. with a rheumatism in her hip 
joint, which yielded for a while fo the several remedies for that 
disease. In the month of November it returned with great vio- 
lence, accompanied with a severe tooth-ache. Suspecting the 
rheumatic affection, was excited by the pain in her tooth, I di- 
rected it to be extracted. The rheumatism immediately left 
her hip, and she recovered in a [ew days. She has continued 
ever since to be free from it. 

" Soon after this I was consulted by Mrs. T. R., who had 
been affected for several weeks with dyspepsia and tooth ache. 
Her tooth, though no mark of decay appeared in it, was drawn 
by my advice. The next day she was relieved from her dis- 
tressing stomach complaints, and has continued ever since to 
enjoy good health : from the soundness of the external part of 
the tooth, and the adjoining gums, there was no reason to sus- 
pect a discharge of matter from it had produced the disease in 
the stomach." (Doubtless it was due to the irritation and the 
consequent deviation of nervous influence to the suffering parts.) 

Case 2. (Dr. Rush.) Some time in the year 1801, I was 
consulted by the father of a young gentleman in Baltimore, who 
had been affected with epilepsy. I inquired into the state of his 
teeth, (an enquiry which is even yet very unusual in such cases, 



EFFECTS OF DISEASED TEETH AND GUMS. 177 

but which serves to shew the superiority of Dr. R. in judgment 
and comprehensiveness of thought,) and was informed that sev- 
eral of them in his upper jaw were very much decayed. I 
directed them to be extracted, and advised him afterwards to lose 
a few ounces of blood at any time when he felt the premonitory 
symptoms of a recurrence of his fits. He followed my advice, 
in consequence of which I had lately the pleasure of hearing 
from his brother that he was perfectly cured. 

In commenting upon these cases, Dr. Rush remarks : 

" I have been made happy by discovering that I have only 
added to the observations of other physicians in pointing out a 
connection between the extraction of decayed and diseased 
teeth, and the cure of general disease. Several cases of the ef- 
ficiency of that remedy in relieving headache and vertigo, are 
mentioned by Dr. Darwin. Dr. Gater relates that M. Petit, a 
celebrated French surgeon, had often cured intermittent fevers 
which had resisted the bark for months and even years, by this 
prescription." (These cases must have been merely irritative 
fever, appearing, as it generally does, with exacerbations depend- 
ing upon constantly recurring circumstances, such as the stimulus 
of light, food, exercise, &c. They were not true intermittents.) 
He also quotes from the work of Petit, two cases ; the one of 
consumption (apparently) the other of vertigo, both of long con- 
tinuance, which were suddenly cured by the extraction of two 
decayed teeth in the former, and of two supernumerary teeth in 
the latter case. 

In the second number of a late work entitled " Bibliotheque 
Germanique Medico Chirurgicale," there is an account by Dr. 
Seibold of a young woman who had been affected for several 
months with great inflammation, pain and ulcers in her right up- 
per and lower jaws, at the usual time of the appearance of the 
catamenia, which were always deficient in quantity. Upon in- 
specting the seats of these morbid affections, the doctor discov- 
ered several of the molares in both jaws to be decayed. He. 
directed them to be drawn, in consequence of which the woman 
was relieved of the monthly disease in her mouth, and after- 
wards had a regular discharge of her catamenia. 

These facts, continues Dr. Rush, though but little attended to, 
17 



178 EFFECTS OF DISEASED TEETH AND GUMS. 

should not surprise us, when we recollect how often the most 
distressing general diseases are brought on by very inconsiderate 
inlets of morbid excitement into the system. A small tumor 
concealed in the fleshy part of the leg, has been known to bring 
on epilepsy. A trifling wound with a splinter, or a nail, even 
after it has healed, has often induced a fatal tetanus. Worms in the 
bowels have produced internal dropsy of the brain, and a stone 
in the kidney has excited the most violent commotions in every 
part of the system. Many hundred facts of a similar nature are 
to be met with in the records of medicine.* 

When we consider how often the teeth, when decayed, are 
exposed to irritation from hot and cold drinks and aliments, from 
pressure, by mortification, and from the cold air, and how inti- 
mate the connection of the mouth is with the whole system, I am 
disposed to believe they are often unsuspected causes of general, 
and particularly of nervous, diseases. When we add to the list 
of these diseases the morbid effects of the acrid and putrid mat- 
ters which are sometimes discharged from carious teeth, or from 
ulcers in the gums, created by them; also the influence which 
both have in preventing perfect mastication, and the connection 
of that animal function with good health, I cannot help thinking 
that our success in the treatment of all chronic diseases would be 
very much promoted by directing our inquiries into the state of 
teeth in sick people, and by advising their extraction in every 
case in which they are decayed. It is not necessary that they 
should be attended with pain, in order to produce disease ; for 
splinters, tumors, and other irritants before mentioned, often bring 

* I met with a remarkable case of this kind a year ago. A wagoner 
between 40 and 50 years of age, a very athletic man, had been engaged on 
the day previous in lifting some logs of wood, and perceived a little blood 
upon his finger, though no wound could be seen. Early the next morn- 
ing he drove his wagon to the city, nine miles distant. On the road 
he suffered with intense pain in the finger, and when he reached the city, 
he was chilly, pale, and evidently laboring under great constitutional irrita- 
tion. The finger showed no wound. The pain increasing, he with con- 
siderable difficulty reached home. Erysipelas appeared, and he died in a 
few days. 

The season of the year, being winter, precludes the possibility of his hav- 
ing been bitten by a serpent. He was not intemperate in his habits. 






EFFECTS OF DISEASED TEETH AND GUMS. 179 

on disease and death, when they give no pain, and are unsus- 
pected as causes of them. This translation of sensation and mo- 
tion to parts remote from the place where impressions are made, 
appears, in many instances, and seems to depend upon an original 
law of the animal economy." 

Tissot, who wrote nearly a century ago, had become aware, 
from observation, of the great importance of diseases of the 
teeth to the general health. He describes toothache as resulting 
from gout and rheumatism, as connected with disordered sto- 
mach, and as the result of the presence of noxious matters in the 
blood, which, according to the pathology of his day, was the 
mode of expressing what we mean by constitutional yices or 
disorders. He also mentions intermittent toothache, which he 
cured with Peruvian bark ; and neuralgic toothache, which was 
arrested by generous diet and wine. 

Modern medicine, or rather, medical writers, have retrogra- 
ded in some respects, however much they may congratulate 
themselves upon their progress in others. Microscopic soma- 
tology but poorly compensates for that close observation of liv- 
ing disease upon which our fathers deservedly laid so much 
stress. 

In the Dublin Medical Free Press, I find the following case 
recorded : — 

Case 3. Painful affection of the eye cured by extracting a 
tooth. — Dr. Emmeuch relates a case of this kind. A man con- 
sulted him on account of a painful affection of one of his eyes, 
which had lasted fourteen years, and occasioned great suffering. 
There was considerable vascularity of the conjunctiva and scle- 
rotica, especially around the cornea, which structure itself was 
somewhat opaque and spotted. There was a continual flow of 
tears, with pain, and intolerance of light. All these symptoms 
were greatly aggravated by any indiscretion in diet and the use 
of the slightest stimulus, such as a single glass of wine. All 
kinds of remedies had been tried in vain, at different times, and 
the affection seemed incurable. On examination of the upper 
jaw, Dr. E. found a carious tooth in the side corresponding to 
that of the affected eye. The portion of the jaw around the 
tooth was painful, and very sensitive to the touch. The patient 



180 EFFECTS OF DISEASED TEETH AND GUMS. 

thought that the affection of the tooth had begun simultaneously 
with that of the eye. The tooth was drawn, and almost imme- 
diately afterwards the symptoms relating to the eye began to 
subside, and soon entirely disappeared. The affection of the eye 
was evidently the result of sympathy between the second and 
third branches of the fifth pair of nerves. 

Dr. Rush (Med. Inq. and Observations on the Diseases of the 
Mind, p. 33,) observes that " Irritation, from certain foreign 
matters retained in irritable parts of the body, is among the 
causes of insanity. 1 ' He adds, " I once knew some small shot 
which were lodged in the foot of a school-boy, induce madness, 
several years after he became a man. It (insanity) has been 
brought on, in one instance, by decayed teeth, which were not 
accompanied with pain." 

Mr. Koecker has published a number of cases, forcibly illus- 
trating the effect of diseases of the teeth upon the general health. 
From these we select the following : — 

Case 4. " Mrs. P., a lady of great respectabilty, under the 
medical care of Dr. Jule Rucco, of Leicester Square, had, some 
years since, continually suffered from dyspepsia, as well as from 
various kinds of nervous attacks of a very annoying and alarming 
nature. This judicious physician had for a long time suspected 
the cause, and frequently proposed to consult me. By the wish 
of the lady, however, the dentist of the family was at last sent 
for, and three or four teeth and roots were removed, which, ac- 
cording to the assertion of the dental attendant, were all that 
could be extracted. The disease, however, was only aggrava- 
ted by this interference, and the sufferings of the patient in- 
creased more and more. 

" About six months after, the doctor again urged a meeting with 
me on the subject, and at last I was sent for. I found the lady 
laboring under a complete salivation from an extraordinary sym- 
pathy of all the glands in any way connected with the teeth. On 
the previous night, and, indeed, for many nights preceding, she 
had been suffering such violent fits of convulsion as to alarm the 
whole family. The face was affected with an acute erysipelatous 
inflammation, accompanied with headache, as also with consider- 
able derangement of the digestive functions, such as sickness, 



EFFECTS OF DISEASED TEETH AND GUMS. 181 

vomiting, loss of appetite, &c. By examining the mouth, I found 
that the previous dental treatment had been but very partial, and 
I proposed the removal of every tooth and root which produced 
irritation. 

" The lady consented immediately to my proposal, and the 
necessary operations were performed on the 8th of October, 
1824, when nine decayed teeth, some of them mere roots, were 
extracted. The patient was requested to rinse her mouth fre- 
quently with a diluted astringent lotion. By this simple local 
treatment, and by the further medical care of Dr. Rucco, she 
was perfectly cured in about a week after the operation. 

" Very soon after her recovery, the lady was enabled to fulfil 
a promise of marriage which for some time had been prevented 
by her protracted and distressing disease. Since that period, 
she has enjoyed perfectly good health. 

The farther treatment of the case has, however, been delayed, 
on the accomplishment of which, of course, the permanency of 
the cure will depend." 

Case 5. A literary gentleman in the neighborhood of Lon- 
don had been for some years under the medical care of Mr. J. 
Derbyshire, of Greek Street, Soho, on account of a constant 
state of derangement of his digestion. 

Much sedentary occupation, and some excessive grief, had of 
late greatly augmented the distressing symptoms generally ac- 
companying this cruel disorder. His disease had assumed the 
character of hypochondriasis. His spirits were so dejected, and 
the state of his bodily health was so low, that he was no longer 
capable of attending to his ordinary business. 

Having had some conversations with Mr. Derbyshire on thje 
influence of disease of the teeth upon the general health, that 
gentleman was induced, at his next visit, to inquire into the state 
of his patient's teeth, and learning that they were in a very de- 
plorable condition, he proposed a consultation with me on the 
subject. After a particular examination, I found every tooth in 
the patient's mouth more or less carious, or dead, and all the 
gums and sockets in a very diseased state. 

On the 27th of May, 1824, twenty-one teeth and roots were 
extracted, all of which were more or less in a state of putrefac- 



182 EFFECTS OF DISEASED TEETH AND GUMS. 

tion — three large grinders only excepted, which were either 
suffering from complicated caries, or producing morbid irritation 
upon the other parts, from some other causes. 

The mouth was restored to perfect health in the course of 
about six weeks. During the progress of treatment of the dis- 
eases of the mouth, the general health improved very surpris- 
ingly; and after the restoration of perfect health to all the re- 
maining teeth, and their relative parts, the patient enjoyed unin- 
terrupted good health, and returned to his ordinary professional 
avocations. 

Case. 6. The following is a letter which was handed to me 
(Mr. Koecker) hy Miss B., Manchester Street, London, in the 
beginning of the month of May, 1825. The history it gives is, 
perhaps, one of the most distressing cases of its kind, concern- 
ing a lady of great respectability and rank in Scotland, of about 
thirty-eight years of age. Its contents, indeed, are not less re- 
markable for the manner in which they display the uncommon 
fortitude of the unhappy sufferer, than for the striking confirma- 
tion which they give of the facts which I have detailed, as well 
as the description I have given, respecting the present state of 
dental surgery. Considering this evidence as most useful and 
important, I beg to submit to the reader the whole of the fair 
sufferer's most interesting and affecting communication. 

" My Dear I have been so ill since I wrote you last, 

that I have not been able to answer your kind letter. As I can 
express myself to you easier than to a stranger, I shall endeavor 
to give you some idea of my present state, and you can give my 
letter to Mr. Koecker. Constant faint gnawing pains in my 
gums, membrane of my mouth and cheeks, accompanied with 
considerable swelling of the latter, which are always blotched, 
inflamed and irritated, just in the way some people's faces are 
affected when suffering toothache ; my very nose is swelled and 
inflamed, and the muscles of the under part of my face so con- 
tracted and drawn upwards, that I cannot swallow any thing but 
liquids. My mouth is contracted and full of slimy saliva. In 
bed I have constant twitches in my gums, like what I could 
figure electricity. Sometimes my gums and face burn like fire, 



EFFECTS OF DISEASED TEETH AND GUMS. 183 

and sometimes feel as if every nerve and blood-vessel were filled 
with ice, and the sheets near my mouth are wet with saliva. 
All these sensations often run down behind my ears, to my neck 
and arms; and at these times I have a great hurry and agitation 
of spirits, and aching across the breast and heart. To me, one 
of my greatest tortures is the extraordinary inflation of gums, 
particularly towards the roof of my mouth. They feel as if they 
absolutely tore from the bone, hove up, as it were, with the 
wind, and my jaws feel twice too large for my mouth, the pres- 
sure against my face is such. The same sensation often proceeds 
to my cheek bones, which increases the swelling of the muscles 
and the dragging up of the under jaw. 

" I must now go back in my history, that Mr. Koecker may 
know the progress of the last five years of my continued misery. 
But, unluckily, I fear it is impossible to make any one under- 
stand my sufferings, they are so various and complicated. You 
know I always blamed my teeth as the cause of all my sufferings; 
but I am now convinced that the disease is in my gums and 
remains of the alveolar processes; and as I was told that was a 
part of his profession Mr. Koecker was supposed to be very 
skilful in, it makes me very anxious to have his opinion. You 
will remember how long (many months) the sockets of my large 
molar teeth stood open, and even when they did heal up, the 
gums were full of morbid sensibility. When I last saw you, I 
had only about five front teeth remaining, and eight below. 
About 1818 they began to ache a little, and, as usual, to irritate 
and inflame my cheeks. The five upper ones began to spoil ; 
but I fought on with them until the winter of 1819, when the 
inflammation, and the various sensations I have mentioned before 
as now suffering, increasing, and the teeth themselves aching, I 
had them pulled. The gums swelled and inflamed most dread- 
fully, the horrid sensations in the roof of my mouth increased, 
and my face was as bad as ever. In about a month the wounds 
healed, but the gums remained swelled and became a hard white 
gristle. After suffering for many months, I had the gums opened. 
They were so hard and thick, the dentist said they were like 
bone. The sockets were not the least absorbed ; of course, 
rough, and in some parts exfoliated. 



184 EFFECTS OF DISEASED TEETH AND GUMS. 

" The gums were kept open near a month, and caustic applied 
to excite absorption. In the course of this process the point of 
a tooth was discovered in one of the sockets, and extracted. It 
was a full grown eye-tooth, which, for want of room, had never 
made its way down. I was easier as long as the gums were 
open; but just where I was, when they healed up and resumed 
their state. 

" Some months after this, my under jaw became affected; the 
teeth were not spoiled, but became so painful to the touch, that 
I could bear nothing in my mouth to touch them. My lips be- 
came very tremulous, and my hands trembled so that I could 
neither feed nor dress myself. When warm in bed they ceased ; 
but from the moment I rose and began to speak, or let the air 
into my mouth, I never ceased trembling, and the dry wretchings 
(which you remember how tortured I used to be with) increased 
so as to bring on vomiting. I suffered in this way for eleven 
weeks, when, in despair, I had all my remaining teeth pulled. 
The tremblings and wretchings quickly abated, and in a few 
weeks completely left me, and I have never had them since. 
My under gums, even before the teeth were pulled, were a hard 
gristle, and almost as white as the teeth. My gums have been 
often opened to give me relief, but as nothing will induce them 
to suppurate, I get no advantage, the wounding only increas- 
ing the hardness. 

" These gums seem to me to act as levers, pressing on the nerves 
and blood-vessels, and keeping up a constant irritation and in- 
flammation in my mouth and face. 

" Under an idea that my complaint proceeded from neuralgia, I 
was advised to have the mental nerves divided at the chin, which 
did no good, and has created such hard tumors on these places, 
that I think their pressure on the side of the jaw is the cause of 
the twitching pain of my under lip, and the contraction of the 
muscles. 

" I would take it as a great favor if Mr. Koecker would say 
whether he thinks he could be of any use to me here, until I 
am able (which, alas ! I fear I am not,) to come to London ; or if 
he could give me any advice which I might desire to be done 
here ; and if he will be so very good as to mention what are the 



EFFECTS OF DISEASED TEETH AND GUMS. 185 

different kinds of diseases he has ever met with in the gums or 
alveolar processes, and his mode of treatment. There seems to 
be an idea here that if the sockets are not carious, there can be 
no disease there ; but I think Fox mentions otherwise. 

" My upper gums had not been touched for four years, until a 
week ago, when a part was opened that was very troubl esome 
and much swelled. The bone was full of points and inequalities, 
and rough ; sounding gritty, like sand. There was a great deal 
of thick slime, like the white of egg, mixed with blood. Some 
nitrous acid was put upon the wound, to try to keep it open a 
little, but in vain. It is already covered with a new gum, and 
the old thick parts gaping open. I am sure if these old swelled 
gums could be got away, I should suffer less. 

" I should think there is about the eighth of an inch of the 
socket remaining. The ridge of the under jaw is as sharp as a 
knife, and so painful to the touch, when I press it, that it makes 
my face, ears, and neck burn. My lips are painful, and are 
drawn in. I was advised to try false teeth, but they increased 
my sufferings ten-fold, which is very hard, as the clinching of my 
jaws adds much to my sufferings. My eyes are beginning to be 
much affected, which must plead my apology to Mr. Koecker for 
this sad scrawl, which I think you will need to help him to 
decipher. 

" There are various opinions about my complaint. One says it 
is a nervous complaint at the origin of the nerves, affecting the 
extremities of these nerves ; others say it is a nervous affection 
of the dental nerves and their ramifications on the face ; and 
others are of opinion it is an affection of the covering of the 
bone. I am satisfied it is some disease of the antrum. Could it 
injure me to have the antrum opened to ease my mind ? There 
is one place where I think there is part of a fang of a tooth, 
which I am certain was broken, as the dentist burnt the tooth 
without letting me see it; perhaps that may torment me." 

Mr. Koecker gives no opinion upon this case; but the lady 
seems to me to have had more discernment than her professional 
advisers. The disease was probably seated in the antrum, and 
very likely the fragment of fang was the irritating cause. 
18 



186 EFFECTS OF DISEASED TEETH AND GUMS. 

The following cases are reported by Dr. C. A. Harris : — 

Case 7. "In September, 1830, I was consulted by Mr. 

, at that time a resident of New York. Before I examined 

his teeth, he informed me that his general health had been very 
bad for four or five years past, and that he had applied to some 
of the most eminent physicians of New York, Troy, and Albany, 
but had not obtained any permanent relief from his sufferings. 

" The character of the symptoms that prevailed at this time 
was very peculiar. His digestive organs were so much de- 
ranged, that he was obliged to observe the strictest regimen, and 
confine himself to the simplest kind of vegetable food. Besides 
the dyspeptic affection with which he was troubled, he had 
severe paroxysms of headache and vomiting, that recurred at 
regular intervals of from four to five weeks. These were always 
preceded by numbness, which commenced in his tongue and ex- 
tended thence throughout the whole system. This sensation con- 
tinued usually for about two hours, when it was succeeded by 
a violent pain in the head and partial vertigo, from which, in 
about ten hours, he was relieved by vomiting. The effects of 
these paroxysms lasted about ten days, and the other symptoms 
had continued, without much mitigation, for three years. 

" On examining his mouth, I gave it as my opinion that the dis- 
eased state of his teeth 'was the cause of his affliction. This 
idea, though entirely novel to him, he was disposed to believe 
correct, and therefore readily consented to the treatment I 
prescribed. Many of his teeth were much decayed, and nearly 
all of them covered with tartar. The roots of some were de- 
nuded of the gums, the alveolar processes more or less absorbed, 
the gums turgescent, fungoid, bleeding on the slightest touch, and 
of a dark red color. The secretions of the mouth were viscid, 
and their exhalations exceedingly offensive. 

" Such of his teeth as could not be perfectly restored were ex- 
tracted, and as much tartar was taken away as could be con- 
veniently removed at one time, and the rest at subsequent sittings. 
His gums were freely scarified, and a tonic astringent and deter- 
gent wash directed to be used three or four times every day. 
Under this treatment the local affection of the mouth rapidly dis- 
appeared, and in about four or five weeks his teeth and gums 



EFFECTS OF DISEASED TEETH AND GUMS. 187 

became perfectly healthy. His general health also began to im- 
prove, and in about two months it was perfectly restored, and 
has so continued." 

Dr. S , a distinguished surgeon and physician of Virginia, 

reports the two cases following: — 

Case 8. " Mrs. S , a lady of thirty or thirty-five years of 

age, with several children, in easy circumstances, rather delicate 
and of sedentary habits, complained of derangement in the func- 
tions of the digestive organs, with much nervous disorder, and a 
painful sensation about the head, as if there were a pound weight 
on the top of it, with an occasional tightening of the scalp. This 
last sensation, she compared to that which might be expected 
from having the scalp forcibly drawn together on the vertex by 
the clawing of some animal with talons, as a hawk. Her friends, 
at first, thought but little of her complaints, and from their eccen- 
tricity were inclined to believe them, for the most part, imaginary. 
The affection of the head, however, and the sensitiveness of the 
nervous system, evidently increased, until they became so harass- 
ing and acute, that they deprived her of rest and made manifest 
inroads upon her healthful appearance. 

M Medical advice having been now obtained, a regular and care- 
fully directed course of purgatives was prescribed, but with little 
or no advantage. The cathartics having been discontinued, the 
Rub. Ferri, Bark, Valerian, Mineral Acids, Zinc, Assafcetida, 
&.c, were next tried, to which were added frictions and tepid salt 
baths, but still without any material amendment. 

" She now began to have evident exacerbations of fever towards 
evening, which passed off with copious and debilitating sweats 
that much reduced her, and caused her countenance to assume a 
sickly aspect. She visited the watering places in Virginia, but 
though her strength was somewhat recruited, the distressing 
symptoms, with some slight modifications, still continued. She 
was occasionally confined to the house, but generally was able 
to take some slight exercise in the open air. 

" This state of things had continued for eighteen months, when 
the attention of her physician was called to an abscess formed near 
the root of one of her incisor teeth. This brought about an in- 
quiry into the general state of the teeth, of which the following is 
the result : 



188 EFFECTS OF DISEASED TEETH AND GUMS. 

" Mrs. S , at. an early period had bad teeth, which, since 

her marriage, had been gradually growing worse. A few years 
before the time of which 1 speak, two of the incisors of the upper 
jaw were clipped off" close to the sockets, and artificial teeth 
were inserted on the fangs. Much pain, irritation, and swelling 
of the gums and lips followed the operation, and similar symp- 
toms occasionally occurred for a year or two afterwards, and were 
frequently attended with alveolar abscesses. The remaining in- 
cisors of the upper jaw and several of the inferior and superior 
molar teeth were found to be in a dilapidated state. The alveolar 
processes of several of the inferior molars were partially de- 
stroyed, and one or two of their roots were turned on one side 
and clung" to the alveoli by the remaining integuments. 

" The situation of the mouth rendered it quite probable that the 
ill health of the patient arose from the irritation produced by the 
bad state of her teeth ; the more so, as her nervous system was 
exceedingly sensitive. She was persuaded to have the carious 
incisors and the worst of the molars removed, and, a short time 
after this was done, her health began to improve. The affection 
of the head and scalp soon ceased, the nervous symptoms van- 
ished, and she is now in good health and has a set of teeth deci- 
dedly more ornamental than those given her by nature ever were. 
The speedy restoration of her health after the removal of her 
diseased teeth, justifies the conclusion that her bad health 
depended on the bad state in which these organs were found." 

The following case, related by the same gentleman, is particu- 
larly worthy of attention as showing the terrible consequences 
which may result from ignorance of the effects which disease of 
the teeth, or even of a single tooth, is capable of producing in 
subjects of certain constitutions : 

Case 9. " Miss W , a maiden lady of about fifty years of 

age, in comfortable circumstances, and for the most part sedentary 
of habit, had suffered much from pain in the right cheek. For 
some time it was not considered of much moment, but, on its 
continuance, a physician was consulted. 

" He found but a single tooth, one of the second molars, in the 
superior maxillary of the affected side, and that was in a semi- 
decayed state. The gums above the teeth, and for half an inch 



EFFECTS OF DISEASED TEETH AND GUMS. 189 

on each side of it, were much swollen and of a livid redness. 
The tumor seemed spongoid and puffy to the touch, but there 
was neither fluctuation nor abscess. The patient's health had 
not sensibly deteriorated. She said the tumor on the gums had 
existed for many weeks, but had not been attended with any 
remarkable pain until the occurrence of that of which she com- 
plained. She described it as being deep in the cheek and gen- 
erally dull, but now and then, for an instant, sharp and lancinating. 
She said the tooth for several years past, had been accustomed to 
ache occasionally, but that, notwithstanding its decayed state 
it was very useful, and she had therefore declined having it 
extracted. 

" The immediate extraction of the tooth was, however, thought 
advisable, and with her consent, it was effected. A week after- 
wards the spongy tumor of the gum continued, without any 
abatement of the pain in the cheek. The tumor was now laid 
open with a lancet. It contained no matter, but was filled with 
those shaggy or shreddy fungi which are often seen to occupy 
tumors or diseased bones. An abscess or some other affection of 
the antrum was suspected. A perforation was therefore made in 
its cavity and about a table-spoonful of very dark brown matter 
discharged, which gave the silver spoon into which it was re- 
ceived a thin coat of the blackest pigment, and, on account of its 
offensive smell, was almost insupportable. There was a difficulty 
in reaching the disease with remedies, and it was thought advisable 
to enlarge the communication with the antrum. The crown of a 
small trephine was accordingly applied to the alveolar portion of 
the superior maxillary, the soft parts having been first dissected 
up, and a corresponding portion of the bone was removed. The 
end of the little finger could now be introduced into the antrum, 
the inner surface of which, it was easy to perceive, had, at 
several points, been denuded of the pituitary membrane and of the 
periosteum. 

" The disease was now fairly exposed, and nothing could ex- 
ceed the offensiveness of its fetor when not corrected by suitable 
dressings. The usual anti-scptics and detergents were locally 
applied, while tonics and a generous diet were prescribed to sus- 
tain the patient's general health, and every effort was made to 



190 EFFECTS OF DISEASED TEETH AND GUMS. 

substitute a healthy purulent secretion for the ill-conditioned and 
offensive discharge from the antrum, but without any effect. 

" An irremediable necrosis seemed to have taken possession of 
the superior maxillary of the affected side, which soon began to 
come away by piece-meal. In the meantime the soft parts about 
it were laid waste by the phagedenic character of the ulceration, 
and the eye of the same side became seriously affected. The 
disease now progressed rapidly. The perforation of the antrum 
was made on the 11th of March, 1821, and on the 26th of May 
following, the patient was found in a perfect state of apoplexy, 
the disease having penetrated the basis of the cranium and seized 
upon the brain itself. On the 30th of the same month she ex- 
pired, and was thus released by death from the most horrible 
disease that can be conceived, but which had its origin in nothing 
more extraordinary than a neglected carious tooth." 

Phthisis Pulmonalis induced by Dental Irritation. 

Dr. M , an eminent practitioner of this State, reports the 

following extraordinary case : 

Case 10. " In the summer of 1834, I was called to visit Mr. 

D. M , who had come into this neighborhood to obtain the 

benefit of the country air, having resided in Baltimore from his 
earliest youth. When I saw him he was in the last stage of 
phthisis pulmonalis. He gave me the following history of his 
case : 

" About eight years previous he felt a soreness and tumefaction 
in his gum at the posterior part of his mouth, and as he had never 
cut the dentes sapienliae, he thought the disquietude was occa- 
sioned by the progress of one of these teeth, and in consequence 
gave it no attention until the soreness and inflammation had ex- 
tended themselves over the whole surface of his mouth and 
fauces. The tooth not having protruded through the gum, he 
consulted his family physician, who advised immediate extrac- 
tion. 

" In conformity with this advice, he called on an eminent dentist 
of Baltimore, but the tooth not having presented itself and the 
cause of his suffering being doubted, the operation was deferred. 



EFFECTS OF DISEASED TEETH AND GUMS. 191 

His sufferings, however, having become intolerable and the irrita- 
tion having extended itself to the lungs, producing considerable 
uneasiness, he determined, if it were at all possible, to have the 
tooth removed. A few days after, he stated his determination to 
the dentist. The gum was freely split, and after considerable 
pain and difficulty, the tooth extracted. The inflammation in his 
mouth and fauces immediately subsided, his appetite returned, 
and his general health soon became as good as formerly. 

" About three years subsequent to this, his mouth and fauces, 
under similar circumstances, and from the same cause, became 
very sore and painful. The inflammation soon reached the lungs 
and established a confirmed phthisis pulmonalis. He died a few 
weeks after my first visit." 

The subject of this case was doubtless the victim of tubercu- 
lar disease of the lungs. The tubercles were latent until the 
dental irritation was propagated to them, when inflammation and 
softening rapidly ensued. The teeth, though they did not, strictly 
speaking, cause the consumption, evidently precipitated it and 
perhaps anticipated the fatal development by many years. The 
same physician, to whom we are indebted for the preceding case, 
has recorded another, in which the fatal result was more directly 
attributable to dental suffering. He says : 

Case 11. "My friend, Dr. L , of Frederick, Md., was 

called to visit a young gentleman who labored under violent pain 
of the face and inferior maxillary, with very great tumefaction of 
the gums. His sufferings were traced to the roots of one of his 
molar teeth, which had been broken in an attempt to extract it. 
His gums and the glands of his throat became so much enlarged, 
that it was impossible to remove the offending portion of the tooth. 
The inflammation, notwithstanding the skilful exertions of the 
physician, rapidly increased, high and intractable fever super- 
vened, deglutition became totally obstructed, and, in a few days, 
he died." 

Case 12. A case very similar to the last, though more for- 
tunate in its results, came within my knowledge lately. A den- 
tist was applied to to extract a molar tooth, which he did. He 
told the patient that the tooth had come out entire; and dismissed 
him. Violent inflammation ensued, a large abscess formed, and 



192 EFFECTS OF DISEASED TEETH AND GUMS. 

the life of the man was brought into imminent jeopardy. His 
physician called in a surgeon, and both being baffled, an eminent 
dentist was consulted. He suspected that a fragment of the 
root had been left , and after great difficulty, owing to the swel- 
ling of the parts, he succeeded in extracting it, and saving the 
life of the patient. 

Dr. Fitch, in his " System of Dental Surgery," narrates a 
number of cases of constitutional disease, evidently caused by 
the protracted irritation incident to diseased conditions of the 
teeth and gums, from which I select the following : — 

Case 13. "In February, 1827, Dr. Samuel Jackson called 

and requested me to see Mrs. It , living in Tenth above 

Walnut street, who, he said, was laboring under every symptom 
of confirmed phthisis pulmonalis, and also appeared to suffer 
greatly from a diseased state, of her mouth. I, accordingly, 

called on Mrs. R . The following were her symptoms. 

Great emaciation, hectic fever, almost constant cough, nearly 
a total loss of voice, articulation being extremely difficult, the 
voice as if speaking through a trumpet. Dr. Jackson said that 
in the practice of seven years in the hospital, almshouse, and 
private practice, he had never seen a person recover from the 
symptoms under which Mrs. R labored. 

" The following was the condition of Mrs. R 's mouth. 

About two years before she had the upper wisdom-tooth of the left 
side plugged, and the plug was pounded in by a mallet and punch. 
The fangs of the tooth converged together so as to form a fang 
of a conical shape. In hammering in the plug the socket was 
much injured. A chronic inflammation took place, which passed 
back over the palate, half arches, and some distance down the 
aesophagus, also over the glottis, epiglottis, and larynx. It then 
traveled forwards on the right side of the under jaw, and caused 
to inflame and slough away all the sockets and teeth of the lower 
jaw but one, which was the left dens sapientias. When I first 

saw Mrs. R the process of inflammation, sloughing, and 

gangrene was at its height. Extensive exfoliations of the jaw 
were taking place. Dr. Jackson and myself concluded that the 
patient could not live more than four weeks. 



EFFECTS OF DISEASED TEETH AND GUMS. 193 

" Treatment. I at once removed all the teeth that were loose, 
and whose sockets were in a state of gangrene and exfoliation. 

I likewise, as fast as possible, removed all the dead bone, and 
directed the patient to wash her mouth constantly with a strong 
infusion of powdered galls. In about eighteen days her mouth 
was perfectly well. The amendment of her general health was 
surprisingly rapid. In five weeks she was able to take long 
walks in the street, and in six months she was restored to perfect 
health. Nearly six years have passed away, and she still con- 
tinues perfectly well." 

As a corollary to this case, Dr. Fitch very properly observes : 

I I think we may safely infer, although diseased teeth do not, 
in every instance, excite general diseases of the system and of 
the lungs, yet, like an insidious enemy, they are ever ready to 
unite with or exasperate other causes, so as finally to undermine 
the powers of the system. I would earnestly solicit the atten- 
tion of the medical faculty in general to a critical inquiry into 
the state of the teeth in all cases of pulmonary affection, and 
there is hardly a doubt that their inquiries would result in the 
general conclusion that a diseased state of the teeth and gums do 
very frequently excite pulmonary affections, especially in per- 
sons predisposed to them, and always aggravate these com- 
plaints, let them be excited by whatever cause they may." 

Professor Chapman, of the University of Pennsylvania, in his 
lectures related the following case : — 

Case 14. " Some years since a lady came from a distant 
part of the country to this city, in pursuit of medical aid, and 
placed herself under the care of Dr. Chapman. He found her 
laboring under every symptom of obstinate dyspepsia, by which 
her health and strength were greatly impaired. His correct 
and well known acumen in the pathology of disease immediately 
led him to inquire into the state of her gums and teeth. He 
found her gums in a high state of inflammation, and many of her 
teeth loose and diseased. By the direction of Dr. Chapman 
she applied to one of our most respectable dentists, and had her 
mouth and teeth placed in a healthy condition, and with the 
return of health in her teeth, gums, &c, every dyspeptic symp- 
tom left her, and she became quite well. 
10 



194 EFFECTS OF DISEASED TEETH AND GUMS. 

" After some time had elapsed, and the lady's health seemed 
confirmed, she had a few artificial teeth placed in her mouth to 
supply some which she had lost, which, either from not being 
well adapted and properly inserted in her mouth, or from some 
peculiarity in the lady's constitution, proved a source of irrita- 
tion, and brought on a return of the distressing dyspeptic symp- 
toms, which compelled her to dispense entirely with the artifi- 
cial teeth, when her health was again completely restored." 

The celebrated Baglivi observes that " Persons whose teeth 
are in an unclean and viscid state, though daily washed, have 
universally a weak stomach, bad digestion, and offensive breath, 
headache after meals, generally bad health and low spirits. If 
engaged in business or study they are irritable and impatient, 
and are often seized with dizziness. From weakness of the 
stomach they are naturally somnolent, scarcely wakeful in the 
morning, and never satisfied with sleep." 

Hufeland enumerates sound teeth among the signs of long life. 
" For good digestion," he says, " good teeth are extremely 
necessary, and one, therefore, may consider them among the 
essential properties requisite for long life : and in two points of 
view — First, good and strong teeth are always a sign of a sound, 
strong constitution and good juices. Those who lose their teeth 
early, have, in a certain measure, taken possession of the other 
world, with a part of their bodies. Secondly, the teeth are a 
great help to digestion, and, consequently, to restoration." 

Mr. Liston observes :* " From the presence of carious teeth, 
or decayed portions of teeth, many evils, both local and general, 
ensue, besides inflammation and abscess. They are frequently 
the cause, and the sole cause, of violent and continued head- 
aches; of glandular swellings in the neck, terminating in, or 
combined with, abscess; of enlargement and inflammation of the 
tonsils, either chronic or acute; of ulcerations of the tongue and 
lips, often assuming a malignant action from continued irritation ; 
of painful feelings in the face, tic-doloureux, pains in the tongue, 
jaws, &c; of disordered stomach from affection of the nerves, or 

*Liston's Surgery. 



EFFECTS OF DISEASED TEETH AND GUMS. 195 

from imperfect mastication ; of continued constitutional irritation, 
which may give rise to serious diseases." 

Case 15. (Dr. Fitch.) "Mrs. S , aged about 38 years, 

was sent to me, by one of our most eminent physicians, with a" 
request that I would examine her teeth, and perform such opera- 
tions upon them as I judged proper, to render them and the gums 
healthy. The state of this lady's health was miserable ; she was 
harassed by the most distressing symptoms of dyspepsia. Her 
digestion was very imperfect, the stomach irritated, loss of appe- 
tite, and a most melancholy depression of spirits. When she 
first called it was necessary for her to repose herself for some 
time, before she could have her mouth examined. 

; ' Upon examining her teeth and gums, I found nearly all the 
former in a state of disease, and the latter were in a state of sup- 
puration, much inflamed and swollen. A considerable deposit of 
tartar was formed around the necks of the teeth; in several in- 
stances their fangs were denuded of the gum by the deposit of 
tartar, and, in fine, her mouth was in a general state of disease. 
I need not detail the several operations by which her mouth and 
teeth were rendered healthy. Suffice it to say, that in about 
four weeks her mouth was perfectly well. The amendment of 
the general health, after the first operations were performed on 
her teeth, was almost surprising, and would have been entirely 
so to any person not acquainted with the immense sympathy be- 
tween the mouth, gums, &c, and the stomach. 

" Within five weeks after I saw her, every vestige of disease 
in her digestive organs left her, and she was apparently in per- 
fect health." 

Case 16. Neuralgia from diseased teeth. — (Prof. Harris.) 
" The following is one of the many cases of tic-douloureux or 
neuralgia faciei, produced by disordered teeth, that have come 
under my own observation. 

" The subject of it was a lady about forty years, of sedentary 
habits, and naturally of rather a nervous temperament. For sev- 
eral years she had been alllicted at times with a most distressing 
and painful affection of her face, which was pronounced by her 
physician to be tic-douloureux. The pain was sometimes so 
acute and lancinating that it almost deprived her of reason. It 



196 EFFECTS OF DISEASED TEETH AND GUMS. 

generally commenced near or a little anterior to the angle of the 
superior maxillary bone, thence it darted across the face to the 
alee of the nose and then to the temple, forehead and angle of the 
eye, accompanied with frequent and sudden transitions from one 
side to the other, twitching and tremors of the muscles of the 
affected parts and with a preternatural flow of saliva. Her face, 
and sometimes the whole of her head, were rendered so sore by 
these paroxysms, that the slightest touch would produce pain. 

" These paroxysms, although they were generally of short dura- 
tion, frequently recurred as often as ten or fifteen times in twenty- 
four hours, and sometimes lasted ten, sixteen, and even twenty 
days, after which they would gradually subside, having subjected 
her during their continuance to the greatest misery and leaving 
after their subsidence a dull, heavy pain in one or both jaws. A 
sensation similar to this was always (especially in the right side 
of the upper jaw) experienced several days before one of these 
attacks, which often enabled her physician to ward them off, and 
finally led to the detection of their cause. These spasms were 
more severe and occurred more frequently in cold, damp and wet 
than in warm and dry weather. 

" Bark, quinine, carb. ferri, stramonium, belladonna, and vari- 
ous other tonics and antispasmodics were prescribed, but without 
any apparent beneficial effect. Leeching, sinapisms and epispas- 
tics were also of no avail. As a last resort, it was determined 
to divide the affected nerve, but before the operation the physi- 
cian was induced by the pain in the jaws, always preceding these 
paroxysms, to examine the condition of the patient's teeth. The 
examination showed them to be in a very unhealthy state. The 
molares generally, and especially those on the right side, were 
involved in complicated caries. The gums were much tumefied 
and inflamed, and the gums sensitive. 

" Her teeth and gums, from the diseased condition in which 
they were found, were immediately supposed to have some 
agency in producing the affection of the face. A consultation 
with me was therefore proposed, and I was requested to visit her. 

" On examining her teeth, I found that eleven were so much 
decayed as to render their restoration impracticable. It was 
therefore determined to remove them immediately, but it was not 



EFFECTS OF DISEASED TEETH AND GUiMS. 197 

thought proper, owing to her extreme debility and the state of 
her nervous system, that more • than two or three should be 
extracted at one time. 

" So great was her agitation at the mere thought of the opera- 
tion, that notwithstanding the agony she suffered, she could not, 
on my first visit, be persuaded to have even a single tooth ex- 
tracted, but requested me to call on the next day, when she 
promised she would submit to the removal of as many as she 
possibly could. 

" I accordingly called on the following day, and to the aston- 
ishment of her friends, she allowed all her jaw teeth that were 
carious, eleven in number, to be at once extracted. The opera- 
tion at once revealed the cause of her disease. The roots of 
three of these teeth were very much enlarged by bony deposi- 
tions. One of the fangs, was, at its extremity, about the size of 
a pea. Those of the other two were not quite so large, but a 
disposition to exostosis was manifested by all. With the removal 
of these teeth, all symptoms of pain entirely vanished, nor have 
they, to my knowledge, returned since." 

Case 17. Death caused by the extraction of a tooth. — (Jour- 
dain.) " A citizen having submitted to the extraction of a tooth, 
the gums became gangrenous ; the gangrene reached the brain 
and caused death." The same author reports a case of 

Case 18. " Convulsions and death caused by the shortening of 
a tooth longer than the others. A nun of Padua having had a 
tooth shortened in order to get rid of the deformity, died imme- 
diately in an epileptic convulsion. A small fragment of nerve 
was discovered in the section of the tooth." 

This case and others which fortunately have not terminated so 
seriously, should be a warning to all operators upon the teeth, 
not to inflict sudden and violent pangs. Experience shows us 
that a great amount of pain can be endured, if slowly and 
gradually inflicted, while instinct teaches us all to dread sudden 
pangs, even of more moderate intensity. Even in extracting a 
tooth, it is better to operate gradually rather than to wrench it 
out with a sudden and violent effort. If pain be gradually in- 
flicted, the nervous system, conscious of the coming trial, sum- 
mons up all its powers of endurance ; but when taken by surprise, 



198 EFFECTS OF DISEASED TEETH AND GUMS. 

the shock is severely felt and the consequences may even be fatal, 
as in the case just quoted. 

Pain is a great evil. It should never be inflicted unnecessarily, 
and when necessity occurs, the inflictor should use all possible 
means to render the suffering as tolerable as possible. Moreover, 
there is great difference in individuals as to the tolerance of pain; 
even as to the perception of it. Many persons will suffer terribly 
from operations which would not cause serious pain to others. 
The same persons will suffer much more at one time than an- 
other. All these considerations are well worthy the attention of 
the dentist. 

Very severe headache of the neuralgic kind, is frequently 
caused by diseases of the teeth and by the irritation produced by 
the presence of dead roots in the jaw. In illustration of this, I 
will quote a few from many cases : 

Case 19. " Inveterate headache cured by the extraction of 
many roots of cariotis teeth. — (Fabricus Hildanus.) A lady was 
afflicted with a very severe continued pain in the left side of her 
head. The violence of the pain was chiefly experienced in cold 
damp weather. By the advice of her physicians, she had tried 
a great many remedies, internal and external, but without success. 
Finally, I was called to see her. I carefully examined all the 
causes of her malady. I learned from her that for six months she 
was afflicted with an agonizing pain in the teeth of the left jaw. 
After this, the pain somewhat abated, but left a similar one in the 
corresponding side of the head. I conjectured from that the 
headache was caused by the roots of dead teeth. Upon examin- 
ing the upper jaw, I found four carious teeth whose roots were 
deeply planted. I advised her to have them extracted, to which 
she cheerfully consented. I then purged her freely and applied 
cups to her neck and shoulders, and an aposeme to be taken dur- 
ing four days in the morning. On the fifth, while fasting, I ex- 
tirpated the roots." After other treatment of a kind then in 
vogue, but of no utility, the lady recovered. 

Case 20. Headache dependent upon the teeth. — (M. Petit.) 
" The late Princess of Conde recommended to her physicians 
one of her proteges, to be cured of a headache of five years 
duration. She had been bled twenty times, and finally Mr. Petit 



EFFECTS OF DISEASED TEETH AND GUMS. 19 

was requested to bleed her in the throat. This surgeon having 
examined the patient, was led from her complaint of a pain and 
weight in the lower jaw, to look into her mouth. He found some 
irregularity in the teeth, and upon close inspection ascertained 
that the patient had an unnatural number of them, there being 
eighteen in the lower jaw. The second molar on each side 
appearing to be most crowded, he took them out, and in twenty- 
four hours the lady was cured of a headache of five years 
continuance." 

Case 21. Ophthalmia and loss of an eye by abscess upon the 
teeth. — (Fab. Hil.) " A lady of Cologne was for a long time tor- 
mented with inflammation upon the last molar of the left side, 
which was carious. By the advice of physicians, she was fre- 
quently purged, and cupped between the shoulders, but as she 
refused to have the tooth extracted, the continued irritation of 
the gums occasioned inflammation of the eye on the same side, 
which finally destroyed the sight." 

Case 22. Ear-ache cured by extracting a tooth. — (Jourdain.) 
" A lady had long suffered with severe pain in the right ear. 
All the ordinary remedies were used without effect. At length 
she was asked if she had any carious teeth. She replied that 
she had not : that all her teeth were good and never gave her any 
inconvenience. Nevertheless, her mouth was carefully exam- 
ined. At first sight all seemed right, but a close inspection 
showed external caries of the dens sapientiae. As the pain of the 
ear extended to the angle of the jaw, and even a little along its 
base, I persuaded the lady to permit me to extract this tooth, 
which I suspected to be the real cause of the mischief. Three 
days afterwards, the lady was perfectly and permanently re- 
lieved." 

A similar case is reported by Mr. Koecker. 

Dr. Darwin relates several cases of serious disorder produced 
in adjacent parts and in the general system by diseased teeth. 
The following are very remarkable : 

Case 23. " Mrs. , about thirty years of age, was seized 

with great pain about the middle of the right parietal bone, which 
had continued a whole day before I saw her, and was so violent 
as to threaten convulsions. Not being able to detect a decaying 



200 EFFECTS OF DISEASED TEETH AND GUMS. 

tooth or a tender one, by examination with my eye or by striking 
them with a teaspoon, and fearing bad consequences from her 
tendency to convulsions, I advised her to extract the last tooth of 
the under jaw on the affected side, which was done without any 
good effect. She was then directed to lose blood and to take a 
brisk cathartic, and after that had operated, about sixty drops of 
laudanum were given her, with large doses of bark, by which the 
pain was removed. 

" In about a fortnight she took a cathartic by ill advice, and 
the pain returned with greater violence in the same place, and 
before I could arrive, she suffered a paralytic stroke, which 
affected her limbs and her face on one side, and relieved the 
pain of her head. 

" About a year afterwards I was again called to see her on 
account of a pain as violent as before, exactly on the same part 
of the other parietal bone. On examining the mouth, I found 
the second molaris of the under jaw, on the side before affected, 
was now decayed, and concluded that this tooth had occasioned 
the stroke of the palsy, by the pain and consequent irritation it 
had caused. On this account I earnestly entreated her to allow 
the sound molaris of the same jaw, opposite to the decayed one, 
to be extracted ; which was forthwith done, and the pain of her 
head immediately ceased. 1 ' 

Case 24. (Darwin.) Since the above was first published, 
I have seen two cases which were very similar, and seemed 
much to confirm the above theory of sympathetic hemicrania, 
being, perhaps, always owing to the sympathy of the membranes 
about the cranium with those about diseased teeth. 

" Lord M. and Mr. B., of Edinburgh, both of them about the 
middle of life, were afflicted with violent hemicrania for about 
two years ; in the beginning of which time, they both assured me 
that' their teeth were perfectly sound, but on inspecting their 
mouths I found all the molares were now so decayed as to have 
lost their crowns. After having suffered pain for sixteen or 
eighteen months, almost incessantly, in different parts of their 
heads, they had each a hemipegia, from which they gradually 
recovered as much as paralytic affections generally do recover. 
All the stumps of their teeth which were useless were directed 



EFFECTS OF DISEASED TEETH AND GUMS. 201 

to be extracted, as the swallowing so much putrid matter from 
decaying bones, seemed to injure their digestion." 

Sir Henry Halford, in a paper on tic-douloureux, read before 
the College of Physicians, related the following cases which 
came under his own observation : — 

Case 25. " A lady, forty years of age, suffered under the 
violent form of tic-douloureux, at Brighton, notwithstanding the 
careful attention and skill of a very judicious physician there. 
On returning to town, it was observed that the rending spasms, 
by which the disease is marked, were frequently preceded by 
an uneasiness in one particular tooth, which exhibited, however, 
no signs of unsoundness ; but the constancy of this symptom was 
enough to justify the extraction of the tooth in this instance; and 
on its being drawn, a large exostosis was observed at the root of 
the tooth, and the lady never suffered more than very slight 
attacks, and these very seldom, afterwards." 

Case 26. (Sir Henry Halford.) " The late Earl of C. un- 
derwent martyrdom by this disease, and excited the warmest 
sympathy of his friends by the agonies he sustained for many 
years. He submitted to the operation for the division of several 
branches of the fifth pair of nerves repeatedly, by Sir Everard 
Home and Mr. Charles Bell, without obtaining more than tem- 
porary relief. At length he was seized with apoplexy, and lay 
insensible for some days, and in great peril, from the attack, but 
finally recovered. After the apoplexy the paroxysms of tic- 
douloureux became less frequent and less severe, and were ad- 
ministered so satisfactorily by an ingenious physician, who wrote 
his inaugural exercise on the disease. For the last year or two 
of his life his lordship ceased to suffer from the tic-douloureux, 
and died at an advanced age, without any marked malady. While 
I attended him he underwent repeated exfoliations of the alveolar 
process of the teeth, which I thought occasioned his torment." 

Doubtless, the exfoliations being completed, and the disease 
of those parts removed, the irritation ceased, and the patient 
recovered. It is melancholy to think of the protracted suffering 
which rendered the life of this unfortunate nobleman wretched 
and comparatively useless, and which might probably have been 
cured with little difficulty, if such men as Sir Everard Home and 
JO 



202 EFFECTS OF DISEASED TEETH AND GUMS. 

Mr. Charles Bell had been aware of the sympathetic disorder 
which may be, and often is, produced by diseased teeth. These 
eminent gentlemen not only did no good, but they inflicted great 
additional pain on their unhappy patient; but, doubtless, he 
would have fared little better in other hands, for the profession, 
while searching with powerful microscopes for causes of disease, 
entirely overlook the teeth, though reason and experience, the 
demonstrations of the anatomist, and the voices of the most dis- 
cerning of the masters in medicine, are continually pointing them 
to the important sympathies of these organs. 

From its relation to the teeth of the upper jaw, the fangs of 
which frequently perforate its floor, the antrum is often the seat 
of disease of a serious and sometimes fatal character, resulting 
from irritation produced by diseased conditions of these highly 
sensitive organs. Indeed, the teeth are directly or indirectly 
concerned in most of the diseases of the antrum. Boyer, Des- 
champs, Harris, and most others who have written upon this 
subject, give united testimony to this fact. 

Dr. Harris, in the second edition of his valuable work on 
Dental Surgery, records several cases in evidence of the facility 
with which diseased teeth may propagate disorder to the antrum, 
and the formidable diseases which may result therefrom. I 
select the following : — 

Case 27. (Dr. Harris.) " Mrs. L., at twenty-seven or twenty- 
eight years, of a scrofulous habit, had been at times affected, for 
more than two years, with a deep-seated pain in the right side 
of her face, midway between the orbit and the alveolar ridge, 
and on closing the left nostril, and making a violent expiration 
through the right, discharged a slightly, yet perceptibly fetid 
mucous matter which occasionally excoriated the mucous mem- 
brane lining this cavity of the nose. The pain, from the fact 
that it was most severe in cold and damp weather, was thought 
to be rheumatic. General and local bleeding, fomentations, mus- 
tard plasters, purgatives, anodynes, tonics, and many other reme- 
dies, had been employed in vain. 

" A severe paroxysm of toothache, about this time, more than 
two years since she first felt the deep-seated pain in her cheek, 
induced her to apply to me. 



EFFECTS OF DISEASED TEETH AND GUMS. 203 

<c On examining 1 her mouth, the crowns of the second molar, 
dens sapientiae, and first bicuspis of the affected side, were found 
to be destroyed by caries ; the gums, covering the sockets of 
their roots, were inflamed and very sensitive. It was the roots 
of the wisdom or third molar tooth that ached. Extraction being 
the only remedy that held out the least prospect of relief, I at 
once proposed the operation, and, at the same time, urged upon 
her the importance of having the roots of the second molar and 
first bicuspid removed. A great deal of persuasion was neces- 
sary to obtain her consent, she being of an exceedingly nervous 
and timid disposition; but, having made up her mind to submit, 
she determined to have the operation performed immediately. 
She had no cause to regret it; for not only was she freed from 
the annoyance which the roots had occasioned to her tongue, 
gums, &c, but the operation was also followed by a speedy sub- 
sidence of the pain in the cheek, and a cessation of the fetid 
discharge from the nose." 

Case 28. (Dr. Harris.) " In December, 1841, 1 was consulted 

by Mr. S. M. J , twenty-three years of age. He had been 

affected for several months with a dull heavy pain, which, as he 
said, seemed to be seated deep in his right cheek; and, as in the 
case last described, a fetid mucous matter was discharged from 
the nostril of the affected side, on making a violent expiration, 
though it, with the other nasal- cavity, closed. His teeth, to all 
appearance, were perfectly sound; but his gums, around the first 
and second bicuspides and first molar, were inflamed, spongy, 
and slightly ulcerated between their edges and the necks of the 
teeth, from which they had separated, to the edge of the alveoli. 
This condition he attributed to a blow which he had received by 
a fall, upon these teeth, about two years before. It was imme- 
diately followed by pain, inflammation, and, in about two 
months, the exfoliation of several small portions of the alveolar 
processes, which came out through the gum. These were the 
only unpleasant effects which he experienced at the time, but 
afterwards there was always a slight soreness in the teeth that 
had received the injury. This gradually extended higher and 
higher into the substance of the jaw, until about four months pre- 
viously to his calling upon me, when its place seemed to be 



204 EFFECTS OF DISEASED TEETH AND GUMS. 

taken by the kind of pain first described, and soon after, the 
fetid discharge from the nostril was discovered. 

" That the deep-seated pain in the right superior maxillary 
was occasioned by inflammation of the mucus membrane which 
lined the sinus, I could not doubt; and that this had resulted from 
the alv r eolar irritation caused by the violence that had been in- 
flicted upon the bicuspides and first molaris, to me, was equally 
evident. I therefore proposed the extraction of the teeth, to 
which he consented. Three weeks afterwards the pain in his 
jaw had entirely disappeared. 

Case 29. (Dr. Shepherd.) Neuralgia vs. Toothache. — "Neu- 
ralgia has become a very fashionable disease now-a-days, and 
many persons suffer long and severely, and ransack the whole 
materia medica in search of remedies ; and finally an examina- 
tion of the teeth is thought of, the very first thing that should 
have been done. In nine cases out often of supposed neuralgia, 
the extraction of some badly-decayed tooth, which the suffering 
individual knows ought to have been out more than a year 
ago, perhaps, would cause a subsidence of all symptoms of 
neuralgia. 

" As a prominent example of the above, I am induced to re- 
port the following case : — Miss C. W., a resident of this town, 
of delicate constitution, was attacked with severe pain in the 
right side of the head, neck and shoulder, about twelve months 
ago ; and from the severity of the pain, and other circumstances 
attending it, she came to the conclusion that it was neuralgia ; 
and by concurrence with her medical adviser, her opinion was 
confirmed. She used, therefore, all possible remedies for that 
disease, without success. In the meantime her attacks were 
growing more frequent and more severe ; and for the last two or 
three months, they occurred daily at precisely five o'clock in the 
afternoon, and continued with the most intense severity until 
midnight; when the pain would begin gradually to subside, 
growing less and less until she was perfectly easy. These daily 
attacks came on with such perfect regularity that, to use her 
own words, ' five o'clock was a terror to her before it came.' At 
this stage of the disease she was in Baltimore, whether in search 
of medical advice or not, I do not know; but while there she 



EFFECTS OF DISEASED TEETH AND GUMS. 205 

consulted Dr. B., an eminent physician of that city ; and he ad- 
vised her to have her teeth examined, intimating that they might 
be involved ; he gave her, at the same time, a prescription for 
neuralgia, to be used in case the teeth were not at fault. With 
this advice she returned home, and sent for me, and related to 
me substantially what I have stated above. 1 examined her 
teeth, and found the inferior wisdom-tooth of the right side de- 
cayed to the nerve, and I gave it as my opinion that all her 
1 neuralgia' originated there ; I therefore advised its immediate 
extraction, to which she assented. The first day after the tooth 
was extracted she had very little pain, the next still less, and the 
third none at all. 

" Thus a perfect cure was effected, of what perhaps nineteen 
out of twenty of our very best physicians would have pro- 
nounced neuralgia, without once thinking of the teeth, by the 
simple extraction of a bad tooth. 

" I do not offer the above as a case of rare occurrence ; I have 
often met with such in the course of my dental practice, as doubt- 
less dentists in general have ; and I cannot account for the fact, that 
physicians so generally prescribe for neuralgia, without once 
thinking of the teeth, when there is so striking a similarity to 
true neuralgia in many cases of toothache. In the case above, 
there were some striking peculiarities, which would have been, 
perhaps, sufficient to screen the most vigilant from the charge of 
superficiality in the examination of his patients, though he might 
have forgotten the teeth. The duration, the regular increase of 
pain, the extent to which the system was affected, and when the 
attacks became daily, the perfect uniformity as to the time of 
commencement, together with the nervous temperament of the 
subject, were all circumstances well calculated to mislead the 
judgment ; and yet this proved to be a case of toothache, a fact 
which might have been proved just as easily in its very com- 
mencement, if an examination of the teeth had been once 
thought of as a matter of any consequence. 

The cases above-mentioned, are but a few of an unlimited 
number that might be collected, showing the importance of the 
teeth, in their healthy and unhealthy conditions, to the well- 
being of the whole economy. Surely those here presented will 



206 * EFFECTS OF DISEASED TEETH AND GUMS. 

be sufficient to arouse the physician to the necessity of regard- 
ing the agency of these organs in the production and continuance 
of diseases, and to impress the dentist with the importance of 
pursuing his vocation, not as a mere mechanical craft to be ex- 
ercised upon isolated excrescences of the body, but as a part 
of curative science, embracing in its relations, the knowledge of 
diseased life as manifested by many organs, or by them all. 
The general surgeon must be more than a mere cutter of flesh 
or setter of bones; the obstetrician more than a man midwife; 
and the dentist is unworthy of the confidence or respect of the 
community who is not well informed upon the nature and history 
of disease, and the part which the organs upon which he ope- 
rates perform in its causation, or modification. 

It is strange that physicians have paid so little attention to this 
subject. It would be less so, if so many of the ablest writers 
among them had not so earnestly and repeatedly proclaimed the 
importance of giving to the teeth their due consideration in the 
diagnosis of disease. But when Hunter, Rush, Darwin, Hal- 
ford, Chapman, and many such men, have taken special pains to 
direct the attention of the profession to the subject, it is unac- 
countable that their voices have been altogether unheeded. 

Unfortunately, it has now become the fashion to study patho- 
logy in the corpse-house, rather than by the bed-side ; to make 
microscopical inquisitions of disease upon the dead, rather than to 
observe its phenomena in the living. From the very necessity of 
the case this necrological research falls into the hands of the 
young and inexperienced, and these become writers and teach- 
ers before they have been to the only sure school of medicine, 
the chamber of the sick. As the teeth may be seen by the 
naked eye, they are not likely to be considered of much im- 
portance. Had they been discernible only by the microscope, 
they doubtless would have received due consideration. It is 
said that the celebrated Pennant, by use of the microscope, lost 
the use of his eyes. I fear that this is too commonly the fate of 
his successors. 

I fully coincide with Dr. Fitch, who well remarks : " We are 
not to contemn the diseases of the teeth because they seem in- 
significant Many persons are formed of a fibre so fragile, as to 



EFFECTS OF DISEASED TEETH AND GUMS. 207 

be broken by the slightest shock ; of a stamina so delicate, as 
to be affected by the slightest impression. Disease in its steps 
at first is, as it were, soft and hesitating, weak in in its powers, 
and slow in its progress. But every instance of indulgence, and 
each succeeding advantage gained, confirms its step, increases 
its powers, and hastens its progress, and what but a moment 
ago seemed a thing too insignificant to mention, now rises a 
monster that derides human effort, and whose sting is the arrow 
of death. 

" Almost inappreciable are the beginnings of many fatal dis- 
eases ; and could the grave reveal its secrets, I have not a doubt, 
when I consider the number of diseases produced by diseased 
teeth, that it would be found that thousands are there, in whom 
the first fatal impulse was given by a diseased state of these 
organs ; and could I raise my voice so as to be heard by every 
medical man in America, I would say to them, attend to your 
patients' teeth, and if they are diseased, direct such remedies as 
shall restore them to health ; and if in health, such means as will 
keep them so." 



CHAPTER XV. 

WOUNDS OF THE MOUTH AND FACE. 

The face, with all the organs which enter into its structure, is 
exposed to the several forms of injury which are known by the 
common name of wound. f 

Surrounded as the human body is by a great number of sub- 
stances denser and more resistent than itself, it is liable to have 
its tissues separated, penetrated, torn, violently compressed, and 
broken asunder. Consisting, also, of a number of elements con- 
stituting organized parts and held in union by the mysterious 
force of vitality, it is also liable to have this union dissolved by 
the action of forces more powerful than life, and to be chemically 
disintegrated. 

As the face, from the necessity of the case must be uncovered, 
and as from its position it is most liable to be injured by falls or 
reached by malicious blows, it is more frequently wounded than 
any other part of the body; and owing to the deformity which 
attends scarring of the countenance as well as the importance of 
the organs connected with it, facial wounds require more nicety 
in their management than any others. 

The mouth is very frequently involved in these injuries, and 
the teeth are often displaced or fractured by them. The mani- 
pulations required for the reparation of these injuries require 
a dexterity only to be acquired by daily observation of the teeth 
in their natural positions and the habit of handling and operating 
upon them. The dentist, if believed skilful, is therefore often 
called upon, even by the general surgeon, to aid in the manage- 
ment of such cases. 

In medical language, a wound is a recent lesion or interruption 
of the continuity of parts from an external cause ; but the term 
is made to include all hurts received from agents acting 
mechanically or chemically upon the surface of the body. 
21 



210 WOUNDS OF THE MOUTH AND FACE. 

Wounds differ materially from one another, in kind, extent, 
position and character of the parts wounded. 

When the parts are merely divided by a clean, sharp instru- 
ment with as little injury to the separated tissues as possible, the 
wound is called a Simple Incision — (simple incised wound.) 

If the parts be rudely torn asunder, the injury is called a 
Laceration — (lacerated wound.) If the parts be violently and sud- 
denly compressed, so as to rupture some of the small vessels and 
break or otherwise injure the muscular fibre, skin, &c, the injury 
is called a Contusion or Bruise — (contused wound.) If a pointed 
instrument be forced into the body, penetrating tissues, it causes 
a Puncture — (punchcred wound.) If a bone be broken, the wound 
is called a Fracture. Injuries from bodies propelled by gunpow- 
der are called Gun shot wounds, and by fire, Burns. To these 
may be added Poisoned wounds, or those in which a slight punc- 
ture or trivial laceration becomes the means of introducing 
venomous matter into the system ; such wounds are inflicted by 
certain insects, serpents and rabid animals. 

Simple Incised wounds are, per se, the least serious of all in- 
juries, though from the flow of blood which attends them, they 
are generally the most alarming. 

In these cases the parts are simply separated, of course not 
without injury at the immediate line of division, but without any 
which suspends the vital action of the separated surfaces, or 
breaks up their relation so as to render re-adaptation difficult. 

Of course these wounds may be of the most serious nature, or 
immediately fatal, if large vessels be divided or vital functions 
interrupted by them. In these cases, the danger is not from the 
nature of the wound, but from the accident of its seat. 

Commonly the most alarming and most dangerous complication 
of incised wounds, is the bleeding or hemorrhage which attends 
them. This will be greater or less, according to the size and 
character of blood vessels divided, the form of the incision and 
the vascular activity, &c, of the patient. 

A wound of this character may be attended by venous or arte- 
rial hemorrhage. 

A slight incision will commonly be attended by a gush of dark 
colored blood from the superficial veins. This flows freely for 



WOUNDS OF THE MOUTH AND FACE. 211 

some minutes, but if the wounded part be not efficiently bathed, 
and especially if it be bound up, the hemorrhage soon ceases, and 
does not again return. 

Sometimes the gush is so considerable as to cause the patient to 
faint, or, in medical language, to induce syncope* In this con- 
dition the patient has temporarily lost his consciousness, his skin 
has become cold, and his pulse ceased to be perceptible. 

This state, though apparently very dangerous, is by no means 
so, unless the patient has previously been much exhausted. On 
the contrary, it is salutary ; for it checks the hemorrhage and 
affords time for the permanent closure of the wound in the way 
to be described presently. 

As the syncope depends upon the want of circulation through 
the brain, the patient should be placed in a recumbent position 
with his head low. If fainting be feared in any case, this is the 
best position and the best means to prevent it. 

The arrest of venous hemorrhage depends upon the' singular 
and most important quality possessed by the blood to solidify or 
coagulate when exposed to the air. Without such a provision, 
the slightest wounds would be very troublesome, and often fatal. 

As soon as a coagulum forms about the orifice of the wounded 
vessel, the bleeding ceases, and the current of blood finding no 
longer an artificial egress, pursues its natural course. 

It is evident that if the flow of blood be very great, or if the 
wound be very large, the coagulum will be longer in forming a 
sufficient barrier to the hemorrhage. For the blood must be at 
rest before it can coagulate, and the amount which, under these 
circumstances, will be arrested by the edges of the wound, etc., 
and detained until coagulation, will bear but a small proportion to 
the current, and will be constantly washed away by it. 

It is in such cases that fainting is sure to occur, and by this 
means the flow being stopped, the blood at the moment filling the 
wound is arrested and coagulates before the action of the heart is 
recovered. 

Sometimes, however, it happens that small veins will bleed 
obstinately and profusely ; owing to the peculiar irritation of the 
wounded part or the indisposition of the blood to coagulate. 

# Syncope, Zvyx.oTru — I fall down. 



212 WOUNDS OF THE MOUTH AND FACE. 

It is evident that compression of the lips of a wounded vessel 
so as to obstruct its channel, is the readiest way to stop the 
hemorrhage, and that as the flow of blood in the veins is towards 
the heart, the pressure should, when these vessels are wounded, 
be especially upon the distal extremity of the wound. Inasmuch, 
however, as the veins anastamose* freely, pressure must be 
exerted upon both sides of the wound. 

As soon as the flow of blood through the vessel is arrested, 
the blood begins to coagulate at the point where it is impeded, 
and in a little while a plug of coagulum effectually stops each 
end of the divided vein. 

It is never necessary to tie a vein, unless it be of the largest 
size, and the operation is always very dangerous. Arteries may 
be tied with impunity ; but the veins, when thus treated, are 
very apt to develop an inflammation of their lining membrane 
(phlebetisf) which is rapidly propagated to the heart, and is 
generalfy fatal. 

Styptics,| of many kinds, have been employed more or less 
for ages, for the stay of hemorrhage. 

These are astringent substances which corrugate the animal 
fibre, thus contracting the orifice of the wound, or articles of a 
porous or loose texture, which arrest a considerable quantity of 
blood, and thus form a clot. 

Alum, the mineral acids, cold water, &c, are of the first class ; 
agaric, sponge, spider's web, fur, &c, of the latter. 

These articles are only useful where small superficial vessels 
are concerned. 

Arterial is far more serious than venous hemorrhage. The 
arteries circulate more blood and with more rapidity. The 
blood from an artery is red, that from a vein purple and nearly 
black; the blood from a vein flows steadily, from an artery it 
flows by leaps or jerks (per saltern.) These characteristics will 
serve to distinguish the nature of the vessel injured. 

The rule, however, is not without exceptions. If a vein lay 

* Anastamose — communicate by a number of mouths — from Ava, and 
Itv^x — a mouth. 
f Phlebetis — from y\t-\>, a vein. % Styptic, from Zrvyeiv, to constringe. 



WOUNDS OF THE MOUTH AND FACE. 213 

directly over an artery, the impulse of the latter may be so sensi- 
bly communicated to the former as to cause the blood to flow per 
saltern. Again, in one instance the author found the venous blood 
of a plethoric patient to be as red as arterial, when issuing from 
the orifice. This, however, is very rare. 

The loss from them is therefore much greater than from veins. 
Moreover, the arteries contract and expand, and force their blood 
by this process, through their canals in jets or gushes. Hence it 
is almost impossible for a coagulum to form of sufficient size to 
resist the force of the propulsion. An artery, unless of very 
small size, if once divided by a clear incision, will continue to 
bleed until the patient succombs from exhaustion, unless artificial 
aid be afforded. 

The means of arresting arterial hemorrhage are, compression, 
ligature, laceration and the actual cautery. 

Compression may be exerted either upon the trunk of the ves- 
sel at a spot nearer the heart than the wound, and where its 
superficial position or relation to a bone renders pressure more 
easy and complete, or upon the lips of the divided vessel. 

Pressure upon the trunk of the vessel can afford but temporary 
relief, as the current of blood will soon find its way through an- 
astamosing branches into the vessel beyond the impeded point; 
upon the lips of the wound, unless very much favored by position, 
it can rarely be perfect, as the arteries for the most part lay deep, 
and the means of compression must be applied at the bottom of 
the wound. 

The ligature is by far the most important of the means used 
for arresting hemorrhage, and the discovery of its adaptedness is 
the greatest advantage of modern over ancient surgery. 

The ancients supposed that the arteries contained a mysterious 
something, which they called the animal spirits, and to prevent 
the egress of this, they resorted to the actual cautery ; thus add- 
ing a most painful and dangerous burn to a wound often large and 
sufficiently serious. 

An artery is composed of three coats, viz : the outer or fibrous, 
the middle or muscular, and the inner or serous. 

When a ligature is tied firmly around the vessel, the outer 



214 WOUNDS OF THE MOUTH AND FACE. 

coat being firm and strong, remains unbroken ; tbe middle and 
the inner or serous coat, are always lacerated. 

The effect of the ligature then is : 1st. To rupture the middle 
and internal coats of the artery. 2d. To bring the lacerated 
parts into close contact. 3d. To produce adhesive inflammation 
by the exudation of coagulated lymph. 4th. To cause the forma- 
tion of a coagulum in the obstructed vessel ; and 5th. To cause 
ulceration of the outer coat, by which the ligature is liberated 
and the wound suffered to unite. 

It appears then that the final closure of the vessel is the result 
of a most wise and benevolent provision of the Creator which 
enables us, through the structure and vital properties of the 
arteries, to procure their obliteration at such point as we may 
select. 

This provision would, however, be entirely nugatory unless 
some means were provided by which parts thus deprived of cir- 
culation should receive it through other channels. But this means 
is provided in the facility with which, under these circumstances, 
the anastamosing branches are enlarged. Through these rapidly 
expanding canals the current of blood presses towards its desti- 
nation, and in a few hours the inconvenience resulting from the 
complete obstruction of such trunks, even as the carotid and 
external iliac, is permanently remedied. 

In placing the ligature, which should be of hard twisted silk, 
around the artery, great care should be had not to enclose in it 
the nerve or vein which commonly attend the former. Serious 
and even fatal consequences would follow such a blunder as this. 
When the external coats of the vessel are so soft as to give way 
before the ligature, a little of the surrounding cellular tissue or 
muscular fibre may be enclosed within the thread. 

The method to be pursued in reaching each particular artery 
will be found in the works on general surgery. It is not within 
the design of the present work to describe them. 

We have mentioned laceration as one of the means of arresting 
hemorrhages. 

When an artery is torn, the internal coat is, of course, brought 
into the condition produced by the ligature, except that the op- 
posing surfaces are not pressed together. It generally happens, 



WOUNDS OF THE MOUTH AND FACE. 215 

however, that the shock of this kind of injury interrupts the con- 
traction and expansion of the vessel, and a coagulum is thus per- 
mitted to form. This mode of operation is only proper when we 
have to deal with small vessels. Their bleeding may generally 
be arrested by seizing them with the forceps and twisting them 
so as to rupture their internal coats. 

The actual cautery* is a terrible means, which should only be 
used under peculiar circumstances. 

We have already said that until within a comparatively short 
period, searing with a red-hot iron was the means commonly 
employed to arrest arterial hemorrhage. Stumps, after amputation, 
were submitted to this dreadful application, adding vastly to the 
terror and pain of operations which even now seem almost too 
severe for endurance. 

The cautery, by disorganizing the extremity of the vessel, 
and corrugating the animal fibre, is an effectual preventive of 
hemorrhage, and may be resorted to when there is no other 
resource. 

It sometimes happens that an injury is done to a bone, which 
opens an artery imbedded in it ; the same happens, occasionally, 
in operating upon these organs. Under such circumstances, it 
is sometimes impossible to use a ligature. 

It also happens occasionally that in the extraction of a tooth, 
a vessel is ruptured which continues to bleed freely for hours, 
and even days, after the injury; and the hemorrhage is not only 
exceedingly inconvenient, but sometimes is sufficiently great to 
be alarming. 

Under these circumstances, after ineffectually stuffing the 
socket with lint, &c, medicated by alum, the mineral acids, &c, 
it becomes necessary to use the actual cautery. 

Owing to the very small surface to which the heated body is 
to be applied, this can be done without much pain to the patient, 
and will, if dexterously accomplished, afford prompt relief. 

A probe ending in a small button, or some other metallic body 
of suitable size and form, should be heated to a white heat and 

*The actual cautery is fire or a heated body, the potential certain chemical 
substance, which combine with and destroy the tissues, as nit. of silver and 
pure potass, &c. 



216 WOUNDS OF THE MOUTH AND FACE. 

carried suddenly to the bottom of the socket. Care should, of 
course, be taken not to touch the tongue or cheeks. 

The potential cautery will also accomplish the purpose, but 
the hot iron is more prompt and not more painful. 

If the hemorrhage from a simple incised wound be merely 
venous, we need not be concerned about it : it will soon cease, 
unless the trunk be very large. 

The treatment of incised wounds, consists in bringing the 
edges of the wound close together and keeping them in contact. 
This done, nature performs the cure by throwing out lymph, 
which cements the adapted edges together, and becoming organized, 
forms a permanent bound of union. 

When this is accomplished without suppuration, it is called by 
surgeons, " the union by the first intention." 

This mode of union leaves but a very slight cicatrix and occa- 
sions the least deformity. It is, therefore, especially desirable in 
all wounds of the face and neck. 

It also is attended with the least possible contraction of the 
parts, and is, therefore, as well as for other obvious reasons very 
desirable in all wounds of the mouth. 

It will be noticed, that we propose no means for curing wounds. 
The truth is, we have none, and none are wanted. Nature is 
abundantly capable of repairing these injuries, if the parts be 
placed in a proper relation, and be protected from the external 
air, which is a positive irritant to the internal surfaces. 

There is no virtue in salves or balsams to heal simple incisions ; 
but these applications may retard the cure and cause suppuration 
where none would otherwise have occurred. 

There are several means for approximating divided surfaces, 
and keeping them in contact. They are adhesive plasters, sutures 
and bandages. 

Of these, adhesive plasters are the most important. They are 
generally sufficient to approximate the parts closely, and unless 
very great nicety be required, will generally answer all desirable 
purposes. 

The solution of gun cotton in ether, which has recently been 
introduced into surgical use, promises to supersede sutures to a 
considerable extent. 



WOUNDS OP THE MOUTH AND FACE. 217 

Stitures or stitches, are threads passed through the lips of the 
wound and then tied, holding the divided surfaces together. 
When very muscular and contracted parts are divided, such as 
the lips or the eyelids ; where it is important to prevent de- 
formity, and where the wound is too deep to be closed by adhe- 
sive straps ; where, from the moisture of parts, adhesive plaster 
would not be available ; or when, as in lacerated wounds^ 
the parts have been broken into small and irregular fragments, 
not affording sufficient sound surface upon which to fasten the 
plasters ; in such cases, sutures are useful. 

Lacerated wounds bleed less profusely than simple incisions. 
The injury done to the vessels is commonly of a kind which 
paralyzes them for the moment, or at least so far enfeebles their 
function as to prevent active hemorrhage. 

This is sometimes the case even when large arteries are torn 
asunder. Cases have been observed where the arm has been 
torn from the shoulder by machinery, and the arteries left hang- 
ing out from the wound, yet no serious bleeding ensued. In the 
experiment of Dr. N. R. Smith, the carotid artery of a horse, 
when ruptured by a blunt hook passed under it, bled but little. 
The absence of bleeding in extensive lacerations, though imme- 
diately convenient, yet indicates an amount of injury to the parts 
far greater and far more difficult to remedy than that which 
attends incisions. 

The parts may be entirely destroyed ; or their vitality may be 
so far lessened as to make them incapable of resisting the in- 
flammation which will result, and cause them to mortify. 

Wounds of this kind do not heal by resolution ; they will sup- 
purate, and consequently the cicatrix that results is more un- 
seemly than is left by simple incised wounds. The pain is 
generally in inverse proportion to the extent of the injury. 
Small lacerations causing great suffering, while those which 
are very extensive, so benumbing the sensibilities as to cause 
but little. A miller, whose arm and scapula were wrenched off 
by a wheel, did not know what had happened until he saw the 
arm revolving round it. There was, as usual in cases of this 
kind, no serious hemorrhage. The indications in lacerations are 
to cleanse the wound of any foreign substances, such as sand, 
22 



218 WOUNDS OF THE MOUTH AND FACE. 

gravel, &c, and to unite the ruptured parts, as nearly as we can, 
without inflicting serious additional injury. 

A difference of opinion exists as to the proper application. 
Inasmuch as the part is at first cold, and the circulation weak, it 
has been the common practice to apply some stimulating appli- 
cations, such as turpentine, or some spirituous preparation ; and 
when inflammation is established, to dress the wound with warm 
poultices, in order to promote the suppuration. 

The most eminent surgeons of the present day, however, pre- 
fer very cold applications, such as ice or ice-water, in order to 
allay the inflammation, which is sure to occur, and which is apt 
to be excessive. 

The probability is that the wound, like an incised wound, 
does better without any dressing at all, except its own blood, 
which protects it from the air and forms a soft, well-adjusted 
cushion between the wound and the bandage, which, of course, 
should be thrown around it, so as to protect it, but loosely. 

The author once saw a wound of this description, of an 
aggravated character, which was treated in the way described, 
by Dr. N. R. Smith. The patient was a boy whose hand had 
been caught in an agricultural machine. His fingers were lite- 
rally crushed : the phalanges splintered, and the flesh torn up and 
hanging in rags about the broken bones. The joints of the fin- 
gers were, for the most part, disorganized, and the organ pre- 
sented so hopeless a condition, that amputation seemed inevita- 
ble, and Dr. Smith was invited to perform the operation. This 
experienced and skilful surgeon, while he admitted the appa- 
rently hopeless condition of the wound, observed, very justly, 
that it would be time enough to amputate when the parts should 
become gangrenous or some constitutional symptoms of an im- 
perative character should supervene : that injuries of the hand 
were not apt to occasion tetanus ; and that he would advise to 
let the hand alone, to see what nature would do. 

A few spiculae of bone were removed, and the hand was, 
without having been washed, bound up in its own blood. 

To the surprise and gratification of all concerned, the wounds 
healed rapidly, and although, from loss of bone and rupture of 
joints, the fingers remained deformed, stiff, and crooked, the boy 
finds them very much more useful than a stump would have been. 



WOUNDS OF THE MOUTH AND FACE. 219 

Contused wounds do not differ very materially from lacerations. 
They, too, require to be let alone, unless the inflammation suc- 
ceeding be so great as to require the treatment heretofore de- 
scribed as proper for such conditions. 

Contused wounds are generally attended by an effusion of 
blood beneath the skin, which gives the parts a black or deep 
blue appearance. As the absorbents slowly take up the extrava- 
sation, the color becomes greenish and yellowish, and finally dis- 
appears. 

With regard to both these kinds of wounds we may say, that 
whatever treatment they require is demanded by the inflamma- 
tion which follows them, and must be modified to suit the 
degree and character of it, without regard to the transmatic 
cause of it. 

Punctured Wounds. — These are injuries made by a pointed 
instrument, penetrating to some depth, and characterized by an 
opening very small in proportion to the extent of the wound. 
Very often, the instrument by which the wound is inflicted is of 
a shape, designedly devised, for the purpose of inflicting the 
greatest possible amount of injury. A bayonet, for instance, is 
triangular and pyramidical, much broader at the base than the 
point. Of course, it is forced into the body like a wedge, and 
bruises and lacerates the parts exceedingly. 

A punctured wound, other things being equal, is a much 
more severe injury than a simple incision. It is both a lacerated 
and contused wound, and of course is fraught with the peculiar 
dangers attending such injuries. But, moreover, it is inflicted 
upon deeply seated parts; vital organs may be reached; large 
vessels and nerves punctured ; even bones penetrated or splin- 
tered. Wounds of the more deeply seated parts do not heal with 
the same facility as the skin ; they are more out of reach of 
dressing and manipulation; they suppurate, and the matter is 
liable to form sacs or pouches, or to be infiltrated into the ad- 
jacent parts, acting as an irritant, and spreading inflammation 
in its course. 

The constitutional impression also is greater when deep 
seated parts are wounded, than when superficial injuries, even 
of greater extent are suffered. 



220 WOUNDS OF THE MOUTH AND FACE. 

The danger of punctured wounds depends upon the extent, 
situation and character of the injury, and the age, constitution, 
&c, of the subject. 

The indications for the treatment of a punctured wound are, 
1st. To remove any fragment of the instrument by which the 
injury has been inflicted ; 2d. To secure any artery which may 
have been wounded ; 3d. To place the part in the easiest and 
most relaxed position ; and, I am tempted to say, 4th. To 
let it alone. I am convinced that much injury is done by 
attempts to aid nature in her efforts at reparation, when she is 
abundantly competent to complete the work without active as- 
sistance. Some surgeons inject stimulating applications, in 
order to bring about inflammation, which is sure to ensue soon 
enough if the health of the patient permit. Others advise to 
lay the w T ound open, and lengthen it so as to convert it into a 
deep incision. This is often impracticable without doing vast 
injury, is always painful, and when accomplished will not pre- 
vent the natural consequences of the laceration already suffered. 
The object of this practice is to prevent the accumulation of 
the matter; but generally the matter will escape readily enough, 
and surely it will be time enough to provide for the evacuation 
of retained matter, when it shall be ascertained to exist. 

Sometimes the lips of the wound tend to heal before the more 
deeply seated parts have established their suppuration. This 
can be prevented by introducing a pledget of lint, or a "tent," 
into the wound, and keeping it there until the growth of granu- 
lations from the bottom and the adhesion of the sides are com- 
pleted. 

The tent should be removed every day, and a shorter intro- 
duced, from time to time, until the cure be completed. 

Constitutional symptoms are to be treated upon general princi- 
ples. Before inflammation is established, and while the system 
is suffering from the pain and shock, opium will be our most im- 
portant means. Should inflammatory symptoms run high, 
blood-letting and other antiphlogistic means will be required. 

Gun-shot Wounds are violent contusions made by dense 
bodies moving with great momentum. The injuries thus in- 



WOUNDS OF THE MOUTH AND FACE. 221 

dieted are serious in proportion to the extent of the wound and 
the importance of the parts involved. These wounds generally 
bleed but little, but even when slight, and penetrating only 
fleshy parts, they produce a remarkable constitutional shock, 
manifested by faintness, feeble pulse and muscular weakness. 

Gun-shot wounds must be treated upon the principles which 
apply to all other mechanical injuries. If the ball or other 
projectile can be removed without difficulty, it should be done; 
if it cannot be readily found and dislodged, it is better to let it 
alone, as much more injury will be done by groping after it 
among the lacerated parts, than by its presence. Generally it 
will come away in the suppuration. Sometimes the wound 
heals over it, and it may remain for years imbedded in bone or 
muscle, without causing inconvenience. 

The notion which prevailed formerly, that lead, when projected 
by gunpowder, is poisonous to the flesh, is a mistake. This 
metal does no injury, except by its weight. 

Burns. — Injuries caused by the action of fire or heated solid 
bodies are indiscriminately called bums : when the result of 
contact with heated fluids they are called scalds. Of course 
injuries from these agents must differ very much according to 
extent and degree; varying from the slightest perceptible ery- 
thema to gangrene of the parts, and from a very limited to a 
very wide spread wound. Indeed, under the common name 
burn, as under the general term wound, are grouped together a 
great variety of injuries, alike only in the fact that they are 
caused by fire or heated bodies. Yet it is common to speak of 
remedies for burns, as though all of these injuries were alike, 
and required the same treatment. There is no branch of sur- 
gery in which empiricism retains its ground as firmly as in the 
treatment of burns. A great number of applications have been 
lauded as specific for these conditions, and when, from some 
terrible accident, a large number of persons are scalded, it is 
mortifying to notice the want of all agreement among physi- 
cians as to the proper management of the distressing cases 
which clamor for relief, and the dogmatic empiricism with which 
nostrums are insisted upon by professional men, who are unable 
22* 



222 WOUNDS OP THE MOUTH AND FACE. 

to give any satisfactory reason for their extraordinary confidence 
in their own suggestions. 

Some years ago a steamboat started from the wharf in this 
city, upon a trial trip, and exploded before she had gone a hun- 
dred yards. Many persons who thronged her decks were 
scalded and blown into the water. When taken out, they were 
chilled and shivering, with feeble pulse, laboring under great 
constitutional irritation. 

Under these circumstances, it was painful to notice the modes 
of treatment adopted, upon opinions of specific virtue in cer- 
tain agents, without any apparent regard to the probability of 
good, as inferred from their known qualities, and the condition 
of parts to which they were applied. 

Cold water, spirits of turpentine, raw cotton, soot, soap, 
with many other applications, have been strongly advocated as 
dressings for burns ; yet certainly it would require an utter dis- 
regard of rational conduct to apply turpentine to the extended 
surface of an abraded cutis, or cold water to the shivering skin 
of a feeble patient, whose whole constitutional effort cannot 
accomplish reaction. 

The danger of burns is in proportion to extent rather than 
degree. A small portion of the body might be burned to 
complete destruction, with far less danger than a large surface 
could be reddened and vesicated. 

' Scalds, therefore, which are superficial burns, are very dan- 
gerous, because, from the diffusible nature of their cause, they 
are generally extensive. 

The reason is, 1st. Because the pain of burns is the prime 
cause of the constitutional distress, and of the serious or fatal 
consequences that ensue, and superficial burns of the skin are 
generally most painful and most extended; 2d. The skin has 
powerful sympathies with the mucous membranes of the bowels 
and lungs, and these are very apt to assume serious inflamma- 
tion when the skin has been extensively scalded. 3d. The 
functions of the skin are important, and cannot be extensively 
interrupted with impunity. 

From the last two causes, it happens that scalded persons are 



WOUNDS OF THE MOUTH AND FACE. 223 

apt to die of pulmonary engorgement, and not because they 
have "inhaled steam," as has been so commonly supposed. 

Where burns or scalds are superficial, the great object is to 
protect the irritated surfaces from the air, which is most dis- 
tressing to them. To this end, nothing is better than the raw 
cotton, which, to prevent its adhesion to the sore, should be 
moistened with some unctuous substance. Linseed oil and 
lime water mixed together are commonly used for this purpose, 
and the mixture answers very well. The cotton thus treated 
forms a soft, warm, innocent dressing, and is as good a sub- 
stitute for the skin, (and this is what we want,) as we can pro- 
cure. Wheat flour or other farinaceous matters sprinkled on 
until the part is completely covered and protected, will answer 
a similar purpose. For obvious reasons, the cotton is prefera- 
ble. A coating of gum arabic, applied in solution, has been 
used with good results. 

If there be no blistering or abrasion of the surface, the injury 
being severe erythema, cold water will give immediate relief. 

Sometimes the part upon which the burn has been immedi- 
ately inflicted will be disorganized or nearly so; the surround- 
ing parts, and those subjacent, partaking of the injury in pro- 
portion to their propinquity to the place of contact. 

In such cases, as the vitality of the parts is nearly exhausted, 
and gangrene likely to take place, the stimulating agents, tur- 
pentine, &c, may be very properly employed. 

In short, the treatment of burns, like that of other injuries, 
must depend upon the judgment of the surgeon, in view of the 
peculiar condition of the injury. 

Burns leave large and unseemly scars, which pucker as they 
contract, and often cause permanent deformity by the shorten- 
ing of skin and muscles. It is important, in the treatment of 
these injuries, to guard against this tendency as much as pos- 
sible, by preventing those positions which, though most easy 
to the patient, will permit the contraction above mentioned. 
Care must be taken, too, that two burned surfaces be not 
brought together and kept in contact. I once saw a child 
< re rendered entirely useless through neglect of 



224 WOUNDS OF THE MOUTH AND FACE. 

this precaution. The palms had been burned, and the mother 
bound up the closed fists, and suffered them so to remain until 
palmar adhesion and permanent muscular contraction rendered 
the organs entirely useless. 

Fractures. 

A fracture is a solution of continuity of a bone, produced by 
violence, acting either by some external agent, or, occasionally, 
by the sudden and extraordinary contraction of muscles. 

A fracture may take place transversely, obliquely, or longi- 
tudinally. The difficulty of adjustment and reparation will be 
in accordance with certain circumstances which give character 
and importance to the injury. 

Cseteris paribus, a simple division of the bone transversely, 
or a longitudinal fissure of moderate length, will involve much 
less suffering from injury to the soft parts, and will be much 
more likely to heal without deformity, than a fracture which is 
oblique; because, in the former cases, there will be but little if 
any displacement of the broken surfaces of the bone, while in the 
latter the muscles attached to the separated part are apt to draw 
it out of its position, and cause it to ride upon the fixed portion. 
The action of the same muscles is of course continually opposing 
the force us ed to keep the restored fragment in place. 

Fractures may be comminuted — that is to say, the bone 
maybe broken into small fragments; they may be compounded, 
that is, may be associated with injuries, more or less serious, 
of the soft parts covering or covered by the bone, such as lace- 
rations of the muscles, skin, protrusion of fragments of bone 
through the integuments, &c. 

Fractures are said to be complicated when attended by some 
accident or condition which materially embarrasses the treat- 
ment and cure. Thus a large artery may be wounded, an im- 
portant viscus injured, or a constitutional disease, affecting the 
vitality of the bones, may exist. 

Treatment of Fractures. — The general treatment of fractures 
consists in meeting the following indications: 1st. To restore 



WOUNDS OP THE MOUTH AND FACE. 225 

the displaced pieces of bone to their natural position. 2d. To 
keep them there; and 3dly. To afford any additional aid 
which the nature of the injury and the constitutional circum- 
stances may require. It does not always happen that the frag- 
ments are displaced. In such cases the duty of the surgeon, 
so far as the condition of the bone is concerned, requires no 
more than to support the parts, and place them in such a posi- 
tion as will best guard against displacement. It will be seen 
that the surgeon has nothing whatever to do with the produc- 
tion of bony union. That is entirely the work of nature, and 
is accomplished by the formation of a hard intermediate sub- 
stance, which is called callus. 

Soon after the injury, a swelling is observed around the 
broken ends of the bone, which gradually hardens until it sur- 
rounds the fracture with a kind of bony splint, within which 
the process of reparation goes on. This is called the provisional 
(Callus, As the cure advances, this hard swelling subsides, 
though it rarely entirely disappears, and the bone is found to 
be permanently united by an organized osseous substance, 
which well subserves all the purposes of the lost bone. 

According to the experiments of Breschet and Villerni, the 
following are the principal circumstances remarked during the 
process of reparation of fracture. 

1. Extravasation and coagulation of a small quantity of blood 
between the ends of the fracture, which blood escapes from torn 
or ruptured vessels. 

2. A fluid, at first of a viscid quality, effused and secreted 
as it were between the periosteum and the bone, and likewise 
exuding from the surfaces of the fracture, and from the soft parts. 

3. A gradual increase in the quantity and consistency of the 
preceding substances blended together, forming every day a 
stronger connection between the parts ; then their change to a 
red intermediate substance between the fragments and between 
the bone and periosteum to a substance which is at first soft, 
but in the end acquires the character of bone. 

4. At the fractured parts a reunion of the periosteum and soft 
parts, which are equally indurated and confused together with 
the intermediate substance between the fragments. 



226 WOUNDS OF THE MOUTH AND FACE. 

5. A diminution and then an obliteration of the medullary 
cavity, at first by a cartilaginous, and then by a bony deposition. 

6. Successive ossification of the whole of the swelling com- 
posing the callus, and of the substance between the fragments, 
preceded by a fibrous and cartilaginous state. 

7. The return of the soft parts around the fracture, and then 
of the periosteum to their natural state. 

8. After the union of the surfaces of the fracture, the medul- 
lary cavity and texture are gradually re-established, and the 
swelling formed by the callus always diminishes.* 

"Whatever may be the process by which callus is formed, it 
is during the first two or three weeks after the fracture that the 
fragments undergo the changes which promote their reunion. 
But it is within the twentieth and thirtieth, and especially be- 
tween the thirtieth and fiftieth days, that nature labors effectu- 
ally in consolidating the callus. Hence, at this period, our care 
to retain the ends of the fracture in exact contact and perfectly 
at rest, should be redoubled, for though there are a few instances 
In which deformity really proceeds from irregular ossification, it 
is a fact that the deformity almost always originates from the 
fracture being disturbed and not kept properly reduced. f 

Fractures of the Jaws. — The lower jaw is liable to be frac- 
tured at any part of its extent, as between the symphysis and 
the masseter muscle, within the muscle, and between it and the 
angle. The bone may also be broken in two places simulta- 
neously. Sometimes, also, the condyles, and less frequently 
the coronoid processes, are broken off. 

Fractures of this bone may be perpendicular, oblique or lon- 
gitudinal. Sometimes a part of the alveolar process with its 
teeth has been split off. 

When the fracture is near the symphysis, the submaxillary 
muscles will draw down the part to which they are attached, 
while the other fragment, released from the counteraction of 
those muscles, will be proportionably elevated by those which 
close the mouth. When fractured in two places, the middle 

* Cooper's Surg. Die, Art. Fractures. f Boyer. 



WOUNDS OF THE MOUTH AND FACE. 227 

fragment will be drawn downwards and backwards, while the 
lateral portions will be supported by their muscular attachments. 
When the fracture occurs within the masseter, little displace- , 
ment can take place, as the muscle attached to both frag- 
ments keeps them in their natural position. 

Fractures of the lower maxillary may generally be detected 
without much difficulty. 

If, after a severe blow or fall, there should be severe pain in 
the jaw, attended with laceration and swelling of the soft parts; 
if the line of the bone be irregular; if crepitus be felt; if the 
gums be denuded, and if the level of the teeth be interrupted, 
there can be no doubt that fracture has occurred. 

Nor is it necessary that all these appearances shall be present 
in order to satisfy the observer of the nature of the injury. As 
the bone can be traced with the finger along its whole length, 
and its level observed both upon the upper and lower margin, 
the displacement or crepitation, and the pain or disability of 
motion, will sufficiently indicate the kind and point of injury. 

There is little difficulty in replacing the fragments of a frac- 
tured lower jaw. We have but to push the displaced part up- 
wards and a little forwards, and press it exactly into a line 
with the fixed portion — observing that the teeth are also 
properly level. It is not so easy, however, to keep the parts in 
their proper place, but the upper jaw being fixed, enables us to 
sustain the lower one against it. 

A piece of pasteboard, moistened and softened with vinegar, 
or, if there be excoriation, with water, is first adapted to the 
basis of the jaw. A four-tailed bandage is then employed to 
keep the parts in position. This consists of a piece of muslin 
or flannel, several inches wide, the centre of which is perforated 
for the reception of the. chin, and the two ends divided longi- 
tudinally, so as to make two tails on each side. The anterior 
of these are carried up the side of the face, and secured to a 
night-cap posteriorly, and the posterior tails anteriorly. The 
patient must keep his mouth closed as nearly as possible, re- 
fraining from talking, and subsisting upon fluid or semi-fluid food. 
Sometimes a tooth will be splii in the fracture, and must be 



228 WOUNDS OF THE MOUTH AND FACE. 

extracted. It sometimes happens, also, that the teeth are so 
irregular as to prevent the complete closure of the jaws, in 
which case a piece of cork may be so placed as to accomplish 
the purpose of supporting the lower by pressure against the 
upper jaw. 

Dr. Rhea Barton, of Philadelphia, devised a bandage for 
fractures of the jaw, to which many surgeons give a preference. 
He commences with a roller an inch and a half wide, below 
the prominence of the occiput, and continues it obliquely over 
the centre of the parietal bone across the juncture of the coronal 
and sagittal sutures, over the zygomatic arch, under the chin, 
and pursuing the same direction on the opposite side, until he 
arrives at the back of the head; he then passes it obliquely 
around and parallel to the basis of the lower jaw over the chin, 
and continues the same course on the other side, until it ends 
where he commenced, and repeats.* 

When the condyle is fractured, the external pterygoid mus- 
cle pulls it forwards, and it is by no means easy to apply such 
a force to the deeply seated fragment as to bring it in contact 
with the body of the bone. Our only alternative is to press the 
lower portion as well as we can to the condyle, by placing a 
thick compress upon the angle of the jaw, and applying our 
bandages so as to press upon this part of the bone. 

Compound fractures of the jaw are to be treated as similar 
injuries elsewhere. Every attention must be paid to ensure 
cleanliness, contact and rest of the parts, and constitutional 
symptoms are to be met by antiphlogistics, anodynes and tonics, 
as cases may require. 

Dislocations] or Luxations. 

The forcing of articular surfaces out of their relative position 
is called a dislocation or luxation, or familiarly, putting out of 
place. These injuries require surgical aid, it being rarely pos- 
sible for the patient to replace the bone by his own efforts. 

* Reese, Note Cooper's Surg. Diet. 
f Dis loco — to get out of place. 



WOUNDS OP THE MOUTH AND FACE. 229 

The cause of dislocations is generally external violence, es- 
pecially falls, but they may be occasioned by the sudden and 
violent contraction of muscles, and these latter are always more 
or less concerned both in effecting dislocation and repairing it. 

Luxations may be complete or incomplete. They are com- 
plete when the articular surfaces no longer touch; incomplete, 
when they remain partially in contact. 

They are necessarily attended with rupture or violent elon- 
gation of ligaments. 

The symptoms of dislocation are pain and incapacity of the 
part, change of position and relation of the bones which form 
the joint, ascertained by the touch and by the position of the 
limb or part. Sometimes, also, special symptoms, indicating 
the pressure of bone upon sensitive or important parts, attest 
the nature of the injury. 

Dislocations of the Lower Jaw. — From the latitude of motion 
enjoyed by the lower maxillary bone, and the necessary loose- 
ness of its articulation, it is very subject to dislocation, though 
this can only take place in one direction, forwardly, and not 
then unless the mouth be wide open and the chin depressed 
greatly at the moment of the injury. 

Sometimes when parties are in high altercation, and one of 
them is vociferating loudly, a blow from the other, falling upon 
the expanded jaws, will put a stop to the flow of epithets or 
recital of grievances, by dislocating the submaxillary. Some- 
times, also, after the jaw has been previously dislocated and 
the ligaments relaxed, yawning will be sufficient to bring the 
condyles to slide forward, and the ligaments giving way, to 
glide beneath the zygoma. 

The injury has resulted from the use of great force in ex- 
tracting a tooth, the jaw being much depressed at the same 
time that great force was exerted upon a posterior tooth, ele- 
vating and pulling forward the posterior part of the bone. 

Dislocations of the jaw are very painful, owing to the pres- 
sure of the condyle's upon the deep scaled temporal nerves, and 
those which go to the masseter, which nerves pass before the 
root of the zygomatic processes. — (Boyer.) The mouth is open 
23 



230 WOUNDS OF THE MOUTH AND FACE. 

and immovable, the patient speechless, the saliva running from 
the mouth, and the countenance expressing great distress and 
anxiety. If the dislocation be long continued, the jaws are 
more nearly approached than when the injury is recent. The 
coronoid process forms under the cheek bone a prominence 
which may be felt through the cheek or from within the mouth.* 

Upon the whole, it is not easy to mistake the character of 
the injury. 

Dentists should be aware of the possibility of such an acci- 
dent as this when extracting a tooth, and should guard against 
such a position of the jaw as would be favorable to it. It may 
happen, however, even in the hands of the most skilful and 
prudent, and they should be prepared to reduce the dislocation 
immediately. 

Mr. Fox dislocated the jaw of a patient on both sides, while 
endeavoring to extract a tooth for him. 

The manner of replacement is very simple. The operator 
must first wrap his thumbs thickly with cloth of some kind, to 
protect them from injury. He must then place them as far 
back in his patient's mouth as he can, and while he depresses- 
the posterior part of the jaw with them, he must elevate the 
chin with his palms and fingers. This process disengages the 
condyles from beneath the zygoma, when the muscles draw 
them into their place with considerable force — enough to lace- 
rate the thumbs of the surgeon, unless they have been well 
guarded against such an accident. 

Sir Astley Cooper placed the patient in a recumbent posture,, 
placed two corks between his molar teeth, and elevated the jaw* 

Efforts at reduction may be confined to one side, if one only 
be dislocated. 

In order to prevent a redisplacement, the jaw should be sup- 
ported for several days, by bandages similar to those employed 
for fracture of the lower jaw, and the patient should be warned 
against opening his mouth more than absolutely necessary for 
the reception of soft food. 

* Cooper's Surg. Diet. 



CHAPTER XVI. 



PARTICULAR AFFECTIONS OF THE MOUTH AND ADJACENT 
PARTS. 

Diseases of the Gums. 

Of inflammation of the gums I have already treated, in con- 
sidering the general subject of inflammation. They are liable 
to other disorders which are worthy of notice. Among these 
are tumors, termed epulis* and parulis.f These tumors differ 
entirely in character. The parulis is an abscess, the result of 
suppurative inflammation ; the epulis a true tumor or morbid 
growth, seated upon and involving the structure of the gum. 
Parulis is therefore a distension of the parts by injected blood 
and effused matter ; parulis is an addition of organized but un- 
healthy substance, increasing the solid bulk of the parts. 

The term epulis is applied to different excrescences seated 
opon the gum. Some are hard, even scirrhous; others soft 
and spongy. Some are developed in the gum itself, others 
have their seat in the membranes of the teeth, periostea, or in 
the dense structures of the bones. 

Of course, as they differ in character and seat, they can have 
no uniformity as to the inconvenience and danger attending 
them. They are generally caused by carious teeth, whose 
fangs keep up a continual irritation in the neighboring parts, 
and are sometimes traceable to neglected parulis or gum boil 
as their immediate cause. 

The most common form of epulis is that of a soft, red, spongy 
mass, which bleeds readily, but is not attended with much pain, 



* Epulis— mi — upon, ovtov — the gum. 
t F'arulis — rtapa — near, ovXov — the gum. 



232 AFFECTIONS OF THE MOUTH. 

as it is not very sensitive. It is liable to be reproduced after 
removal, but, unless improperly treated, is not dangerous. 
Sometimes, instead of appearing externally, the disease com- 
mences in the sockets of the teeth, and loosens and displaces 
them, though they may be perfectly sound. Some swelling of 
the gums and a discharge of pus accompanies this condition. 
A smooth, shining, elastic tumor sometimes shows itself upon 
the gum. It is compressible, but little sensitive, and bleeds 
freely if cut into. It is not malignant. 

A scirrhus may be located in the gum, where it will exhibit 
its distinctive qualities, hardness, acute lancinating pain, and 
unequal surface. It follows the history of similar tumors else- 
where, and is much to be dreaded. 

Another form of carcinomatous affection of the gums is that 
of a soft, spongy, bleeding fungus, much like the first form of 
epulis, but accompanied with great sensitiveness and acute 
pain. 

When these affections, either in their natural progress or from 
ill treatment or injury, assume a rapidly progressive form, very 
terrible phenomena begin to manifest themselves. If previously 
hard they soften, the bones become carious, a fetid and sanious 
discharge is poured out, the teeth are loosened, the devastation 
spreads, the lymphatics swell, hectic supervenes, and after 
much severe suffering the patient expires, from nervous ex- 
haustion, hemorrhage or suffocation. 

When the tumor is of the non-malignant kind, and has not 
so far progressed as to involve a large mass of bone in caries, 
and soft parts in ulceration, it may readily be removed, and its 
return prevented, by the removal of the carious teeth which 
cause it, if, as is generally the case, it has been induced by this 
cause. Without removing these irritants, of course no perma- 
nent cure can be expected. 

When of the malignant variety, the most prompt and 
decided means must be resorted to, to prevent fatal conse- 
quences. 

Mr. Liston and Prof. Mutter both regard genuine cancer of 
the gums as a very rare disease ; but they concur in thinking 



AFFECTIONS OF THE MOUTH. 233 

that such affections are degenerations from original character, 
owing to constitutional causes, neglect or bad treatment. There 
is, therefore, more encouragement to hope for success in the 
attempts made to remove these affections, than when they are 
but the local indications of general disorder. 

The treatment will of course be modified by circumstances. 
If the disease be not malignant, but is evidently a mere fungous 
condition of the gums, depending upon the irritation of a ca- 
rious tooth, &c, it is only necessary to remove the cause of the 
trouble, and then to cut away the tumor, and destroy what may 
remain of it by compression or caustic. 

If the tumor be of the elastic kind, it must be thoroughly 
removed. If it hang by a narrow neck, it may be cut off by a 
ligature. Profuse bleeding is apt to result from incising these 
tumors, and will generally demand the use of the actual cautery 
for its suppression. 

The scirrhous or malignant tumor requires a very thorough 
exsection. Every tooth and all the bony structures in any way 
connected with it must be boldly cut away, and the wound 
seared with the hot iron. 

The mode of operation preferred by Prof. Mutter, and which 
he thinks "better adapted to the case," and fraught with less 
suffering than the use of the mallet and chisel, is thus described 
by himself.* 

"Having placed the head of the patient in a good light, and 
against the chest of an assistant, who stands behind the ope- 
rating chair, the surgeon makes a perpendicular incision on 
each side of the tumor, with a pair of strong scissors, or rather 
cutting forceps, and without stopping to arrest the hemorrhage, 
at once detaches the mass, by dividing the alveolar process 
above or below the tumor, as the upper or lower jaw happens to 
be involved, with cutting forceps, one blade of which is applied 
to the inner portion of the jaw, and the other to the outer. The 
raw surface is next carefully examined, and every vestige of the 
1 removed with a knife or scissors. If the bone appears 

• Listen and Matter's Surgery, p. 285. 
23* 



234 AFFECTIONS OF THE MOUTH. 

affected, it must be cut away, and often a very good preventive 
to the return of the disease is the use of the actual cautery. 
The bleeding may be arrested, either by the cautery, or by 
placing a pledget of lint, dipped in creosote, in the chasm, over 
which a slice of cork may be laid, and then closing the jaws, 
make the sound one act as a compress. To secure the dress- 
ing, the bandage for fracture of the lower jaw may be applied. 
The parts should not be examined in the first twenty-four 
hours; but after this period a daily dressing is required, the 
nature of which depends on circumstances. If there be no 
disposition to a return of the disease, it will be sufficient to 
wash the part with some detergent solution, until cicatrization 
is completed. But if fungous granulations make their appear- 
ance, the vegetable caustic, (caustic potassa,) or actual cautery, 
should be applied, until this disposition in the wound is de- 
stroyed. 

"Instead of using the perpendicular cuts with the short forceps, 
some prefer a thin saw, but the method just described is less 
painful, and accomplishes the object in a much shorter period. 
When the tumor is very large, the saw may be required, and 
should be always at hand, in case the edges of the forceps 
should turn in making the first cut. 

"When the tumor is very large, or seated in the side of the 
bone, or far back, the cheek should be divided, in order to 
enable us to reach it without difficulty. In such cases I have 
found great advantage in using a cutting forceps, so curved as 
to pass readily to the back part of the mouth, and then allow 
of the blades being passed above the base of the tumor, when 
the upper jaw is affected, and below it, when the inferior max- 
illary is the seat of the disease. 

"After the removal of the diseased mass, the wound of the 
cheek may be closed, and union by the first intention attempted; 
and when the dressings are carefully attended to, the deformity 
resulting from the incision is scarcely perceptible, unless the 
portio dura is extensively injured, when paralysis,- generally 
incurable, ensues, often giving rise to a very unpleasant ex- 
pression of countenance." 



AFFECTIONS OF THE MOUTH. 235 

Of whatever kind these tumors may be, they should be care- 
fully watched. So long as they cause no inconvenience, they 
may be let alone, but if, by reason of growth or any other cause, 
they begin to inflame the surrounding parts, or to become pain- 
ful during the movements of the jaw or contact with air or food, 
they should be extirpated. If pendulous and accessible, a liga- 
ture or the knife may be used; but if broadly based and fully 
incorporated with the gum, and but small in size, caustic should 
be used. 

A number of cases have been collected by Jourdain, and 
published in his celebrated work on the diseases of the mouth, 
which show the serious character often assumed by epules. In 
truth, all forms of tumors may appear upon the gum, and the 
only difference to be observed in their treatment in this location, 
grows out of the impossibility of using applications and appli- 
ances which are found useful and convenient elsewhere. So 
far as tumors of the gums are concerned, the treatment is very 
limited indeed. If they contain matter, they must be opened; 
if connected with carious teeth, these must be removed; if with 
carious alveoli or maxillary bones, the treatment must be direct- 
«d to the deep seated cause ; if they are malignant, or if in any 
way inconvenient, they must be removed, either by cautery, 
ligature or incision, as the nature of the case may require. 

Parulis. — Abscess of the gum is so called. It is precisely 
similar to such tumors in other soft parts, and generally, if not 
always, depends upon carious teeth. 

Sometimes the abscess makes its appearance without pre- 
ceding pain, over the fang of a diseased tooth, and after re- 
maining for some time will gradually disappear, the matter it 
contains having been absorbed, or having found vent through 
an opening in the tooth. More commonly, however, the ab- 
scess succeeds a violent and protracted tooth-ache, which is the 
consequence of cold acting upon the irritable nerves of carious 
teeth and bad conditioned gums. The pain is sometimes very 
severe, but at all times there is an aching or throbbing sensa- 
tion, due to the inflamed state of the gum tissue. Sometimes 
several days and nights of severe suffering will elapse before 



236 AFFECTIONS OF THE MOUTH. 

the abscess is seen to elevate itself from the gum : at other 
times it will be formed in a few hours. When first perceived, 
it is a hard circumscribed elevation, either immediately upon 
the gum or in the cellular tissue between the gum and 
cheek. After a longer or shorter time, the tumor softens, the 
pain abates, and fluctuation is perceived in the tumor. If no 
artificial means be employed to evacuate the matter, an opening 
will be made and the matter discharged. Sometimes, though 
very rarely, ulceration will perforate the cheek, and the pus be 
evacuated on the outside. This is an accident much to be 
deplored, and therefore, as soon as fluctuation is perceived be- 
tween the gum and cheek, the pus should be evacuated. 

During the inflammatory stage of the tumor, before pus is 
formed, little can be done except to apply leeches to it. This, 
if applied very early, will sometimes prevent suppuration, and 
more often limit its extent. After the tumor is fully formed, 
however, leeching will do no good. We can only soothe the 
patient by keeping the face warm, applying counter irritants to 
the cheek, and prescribing anodynes. Unless the diseased 
tooth be removed, the abscess will be formed again upon the 
slightest provocation. 

Generally, after the evacuation of the pus, the abscess is filled 
with granulations, and the parts return to their natural state. 
Sometimes, however, the tumor is due to slow suppuration of 
the fang or alveolus, and in this case the matter continues to 
trickle through the opening, the edges of which become thick- 
ened and hard, and a fistula is formed. 

Of course, the only remedy is to remove the diseased tooth 
or bone. 

It not unfrequently happens that abscesses are formed at the 
roots of teeth which appear sound, and after much pain endured 
by the patient, fistulous openings evacuate the matter which 
should have been discharged by extracting the tooth or teeth 
whose obscure disease produced and perpetuated the trouble. 
In illustration of this important fact, I will quote some cases 
reported by Jourdain. 

"The late Mr. Desjardins, surgeon, requested me to visit 
with him M. Rose, Place de Greve. 



AFFECTIONS OF THE MOUTH. 237 

"This patient had been suffering for many days such violent 
pain along the whole extent of his chin, as to prevent him from, 
sleeping at night or pursuing his business by day. As no 
disease could be discovered in his teeth, and as they were not 
at all subject to ache from cold or heat, they were not suspected 
to cause the suffering. The patient was bled, but without effect, 
and the pain becoming excessive, I was called in. I first ex- 
amined the lower incisors, but could discover no signs of dis- 
ease. The other teeth also appeared sound. The lower part 
of the gums of the incisors appeared slightly reddened, but 
without swelling or fluctuation. A little purple exanthema 
upon the right gum was the only additional alteration that we 
could perceive, and this was not sufficient to determine the 
extraction of the tooth. 

"Thus uncertain how to act, I applied a lighted taper to these 
two teeth. From the reflection of the light, we satisfied our- 
selyes that the incisor tooth nearest to the canine was the cause 
<ot all the suffering. The enamel substance seemed to have 
lost its usual transparency. Finally, to be more certain, I 
pierced the exanthema, and serous blood flowed out. The 
stilet pierced the bone and struck the root of the tooth, which 
I extracted. We immediately broke it. The canal of the root 
and the pulp-cavity were filled with a black and very fetid pus. 

"Upon the same day, the patient became entirely easy, and 
in a few days no appearance of disease remained." 

"Fistula of the Gam of the Lower Maxillary, having an Ex- 
terior Opening at the Hollow of the Chin. 

"M. A. Petit called me to see the wife of M. Despinasse, 
whom he had been treating for a long time for a fistula of the 
gum, situated at the lower part of the gums of the two central 
incisors of the lower jaw, and which had an external opening 
upon the fossa of the chin. The teeth were neither loose nor 
altered in color. 

"The patient could give no reason for the occurrence of the 
disease. She looked very well, and was yet young. The 



238 AFFECTIONS OF THE MOUTH. 

ulcer gave us no clue to the cause of it. The condition of the 
teeth made us hesitate to extract them from the mouth of so 
young a woman, and the same reason had hitherto prevented 
such an operation. 

"Various caustics had been introduced into the external 
opening. In short, with the exception of the actual cautery, 
no means had been left untried to heal the fistula. The open- 
ing of the gum had indeed cicatrized, but that of the chin had 
proved intractable. 

"Upon exploring the outer opening, I found that the probe 
penetrated the base of the alveolar and maxillary substance, and 
that these bones were traversed by little canals corresponding 
to the roots of the two teeth. Hence, considering the length 
of time that the disease had resisted all remedies, I strongly 
suspected that the alveolar extremities of these roots were ca- 
rious. I imparted my suspicion to M. Petit, who agreed with 
me that the teeth should be extracted. When the teeth were 
drawn, I examined them. The extremities of their roots were 
black and corroded; the canal was in the same condition, and 
the pulp-cavity contained thick and fetid pus. Suitable treat- 
ment was now addressed to the carious bones, and the fistulas 
soon were healed." 

Spongy or Fungoid Inflammation of the Gums. 

This affection is commonly called scurvy, but improperly so, 
as we have already observed. 

The gums, when thus affected, are darker than usual, swollen 
and less firm than when in health. They bleed freely under 
the brush, or when touched by the lancet, and upon pressure, 
discharge a very fetid pus, which often gives its disgusting odor 
to the breath. 

The gums are generally detached to some extent from the 
teeth, and their margins are thickened. They are often very 
sensitive. 

The extent of the disease, and the inconveniences attending 
it, vary very much. Sometimes it is confined to a very small 



AFFECTIONS OP THE MOUTH. 239 

portion of the gum, being a mere local attendant upon some- 
diseased or irregular tooth, at other times it seems to depend 
upon constitutional causes, and communicates itself rapidly to 
the whole gum structures of the mouth. 

When thus extensive, it develops disease in the periosteum 
of the teeth, causes bone to be deposited in the sockets, spreads 
carious devastation along the whole circle of the jaws, and de- 
spoils the mouth, either by causing the teeth to be pushed from 
their sockets, or by destroying the crowns by devastating caries. 

In the meanwhile the general health suffers. The fluids of 
the mouth are no longer fit to perform their office; the teeth 
cannot masticate the food; fetid pus and blood trickle into the 
stomach, and the patient's nervous system is worn out by fre- 
quent paroxysms of tooth-ache. 

Though certain aptitudes of constitution give virulence to 
this affection, it is mainly a local disorder, originating from the 
presence of decayed teeth and tartar. The latter, gradually 
detaching the gum from the teeth, produces inflammation and 
ulceration of the gum, and accumulating under the opening, 
constantly increases the irritation. 

Dr. Harris mentions a form of this disease met with in per- 
sons of scrofulous habits, which he thinks differs essentially 
from the more common affection. In this case, "the gums, 
instead of being purple and swollen, are paler and harder than 
ordinary, and on being pressed exude a muco-purulent matter 
of a dingy white color. They often remain in this condition 
for years, without appearing to suffer any loss of substance, or 
to affect the alveolar processes. This variety of disease of the 
gums is principally confined to persons who have very white 
teeth, and is much less likely to affect males than females. It 
rarely occurs before the age of eighteen or twenty, and though 
unquestionably the result of inflammation, yet the gums exhibit 
no inflammatory symptoms, but on the contrary are paler, less 
sensible, and possessed of less warmth than usual. It is never 
attended with tumefaction of the gums, and by absorption only 
in its advanced stages. Its effects are the most simple and 
innocent of any form of disea e lo which the gums are liable, 
but its cure h generally more difficult." 



240 AFFECTIONS OF THE MOUTH. 

The treatment of the common form of the affection is simple 
and generally successful, yet it is often comprehensive. Every 
irritant to the gum, whether tartar or teeth, must be thoroughly 
removed. This remark applies not only to diseased but even 
to irregular teeth, and to those which have no antagonists. 
This work of purgation of the mouth being thoroughly done, 
simple astringent washes will do all that is further necessary. 

The scrofulous form of the disorder described by Dr. Harris, 
demands entirely different management. Being but a phe- 
nomenon of general constitutional vitiation, it can hardly be 
permanently relieved by local treatment. Constitutional reme- 
dies, such as proper diet, exercise, air and clothing, iodine and 
cod liver oil, should be prescribed. At the same time, the 
edges of the gum should be touched with lunar caustic, (nitrate 
of silver,) which not only acts as an escharotic by removing 
the diseased surface, but exerts a singularly modifying influence 
upon certain forms of inflammation. 

Hemorrhage from the Gums. 

The gums, like other mucous structures, are sometimes so 
engorged with blood, that it is exuded freely upon the surface,, 
constituting passive hemorrhage. The pathological condition 
attending this sort of bleeding is very different from that which 
is manifested by active hemorrhage. In the former case, the 
exudation of blood is caused by the weakness of the containing 
tissues ; in the latter, by the violence of vascular action. To 
relieve the one, we endeavor to fortify the parts by astringents, 
&c; in the other, to lessen the arterial force by which the blood 
is injected into the distended vessels. Hemorrhage of either 
kind may be due to a rupture of a vessel. This, however, is not 
necessary to hemorrhage, even when profuse. It is much more 
apt to be the case in active than in passive bleeding. 

The hemorrhage from the gums is always passive. Even 
when the tissues are the seat of violent inflammation, they do 
not bleed, but when they are softened and rendered less resist- 
ing by local or constitutional causes, they sometimes permit 
the blood to exude through them to an alarming amount. 



AFFECTIONS OF THE MOUTH. 241 

When the mucous membrane of the gums is thus hemorrha- 
gic, the condition is shared by the membrane covering other 
parts of the mouth. 

I have seen this affection as one of the phenomena attending 
exhaustion from intemperance. 

Occasionally persons are met with, who manifest the hemor- 
rhagic diathesis as an organic idiosyncrasy. In such cases all 
wounds are exceedingly dangerous ; as the blood has too little 
coagulability to form a plug to any divided vessel. Instances 
have occurred, in which persons thus conditioned have bled to 
death from the rupture of trifling vessels in the extraction of a 
tooth. 

When passive hemorrhage occurs from the gums, astringents 
generally fail to check it. Indeed it is almost impossible to 
apply them effectually to every part of the bleeding surface. 

We have, however, a very available remedy in compression, 
which can be speedily and easily applied, by filling a wax- 
holder, such as is employed for taking impressions of the mouth, 
with wax, previously softened in warm water, and then apply- 
ing it in such a manner as completely to imbed the teeth and 
gums in it. This method, recommended by Dr. 0. Holmes, I 
have seen tried successfully in a very obstinate and dangerous 
case. 

When troublesome bleeding results from the extraction of a 
tooth, it may be checked by the actual cautery, or by plugging 
the tooth with a cone of waxed cloth or cork. 

The nitrate of silver will commonly arrest the hemorrhage 
promptly ; but it cannot be safely applied over a very large ex- 
tent of the mouth at once. 



24 



CHAPTER XVII. 



DISEASES OP THE LIPS. 



Hare- Lip. 

This is a congenital deformity, which consists in a fissure 
which divides the lip perpendicularly. Sometimes there are two 
fissures : the former is single, the latter double hare-lip. 

The cause of the deformity is unknown. It is a failure of 
nature, through an inscrutable cause, to complete the union of 
the two sides of the body at this part of the line of junction. 

Sometimes the affection exhibits a single slit, at others two, 
with a lobe or flap between them ; and sometimes the fissure 
extends along the roof of the mouth, the soft and hard palate 
being separated. Generally the lip on both sides of the fissure 
is not adherent to the alveolus, but sometimes it is. 

Most commonly the upper lip only is affected, but sometimes 
the lower is the seat of the fissure. When this is the case, the 
child cannot suck, or learn to speak with any distinctness ; 
adults suffer from the loss of the saliva, which runs freely from 
the mouth, and indigestion is the consequence. This form of 
hare-lip is seldom congenital, but is occasionally traumatic* or 
accidental. 

All degrees of hare- lip are attended with deformity and in- 
convenience, though some, from the extent of the separation of 
parts, are much more annoying and unsightly than others. Mr. 
Cooper describes a form of it, which must, however, be rare, 
in which "the jaw is not only imperfectly ossified in front, so 
that a cleft presents itself there, but one side of it projects for- 

Traumatic — the effect of a wound. 



244 DISEASES OF THE LIPS. 

ward, and is at the same time inclined too much outward, 
drawing with it the corresponding part of the palate and the 
septum nasi, so that a very unsightly distortion of the nostril 
and nose is produced." 

When the fissure pervades the palate, the patient finds it 
very difficult to masticate or swallow, and articulation is neces- 
sarily very imperfect. 

It is obvious that surgical aid must be employed for the 
remedy of the deformity. 

A considerable difference of opinion exists among eminent 
surgeons as to the proper time for performing the operation — 
some advising to delay it until the child shall be four or five 
years old, and others preferring to operate upon the infant of 
months. 

Sir Astley Cooper used to narrate several cases in which a 
fatal termination resulted from too early an operation — convul- 
sions having occurred from the pain and irritation of the wound. 

Undoubtedly, infants may often be operated upon with more 
facility than older children, and in some instances the deformity 
is attended with so much inconvenience as to authorize early 
operations. If, however, the child be able to nurse, and espe- 
cially if it exhibit considerable nervous mobility, it will be 
better to delay the operation for several years. 

Mr. Liston advises to defer the operation until the first den- 
tition shall have been completed. He says, "when the opera- 
tion is undertaken at an earlier period, there is often great 
difficulty. Sometimes union does not take place, the parts 
turn out again, and the patient is rendered more deformed than 
in the first instance. When the features are enlarged some- 
what, you have more ground to work upon ; you can put the 
parts neatly together, and you can almost answer positively for 
the union taking place." 

The cure depends upon the capability of two incised surfaces 
to unite when brought into contact, and the proper performance 
of the operation consists in cutting off the edges of the fissure, 
and keeping the new surfaces so closely together as to procure 
union by the first intention. 



DISEASES OF THE LIPS. 245 

The manner of performing the operation is sufficiently sim- 
ple, yet it requires considerable dexterity to do it well. 

Some surgeons cut off the edges with a pair of strong sharp 
scissors ; others place a piece of wood under the lip, and then 
pare off the edges with a knife ; others, confident in the correct- 
ness of their eye and the steadiness of their hand, place the 
child between their knees, with the head towards them, enter 
the knife into the lip above the angle of the fissure, and carry 
it downwards until it completes the removal of all the portion 
of the lip on that side which is required. A similar cut upon 
the other side prepares the wound for closure. 

The bleeding readily stops upon pressure of the lips, and is 
rarely excessive. 

The wound is closed by the twisted suture ; that is, two silver 
pins, with steel points, are introduced through the edges of the 
wound, penetrating the lip through about two-thirds of its 
thickness, the first near the inferior extremity of the wound, 
and the second a quarter of an inch above. The divided sur- 
faces being thus brought into contact, thread is wound repeat- 
edly around the pins, first transversely and then obliquely, from 
the right side of the upper to the left of the lower, and vice 
versa, until the contact is firmly secured. The points of the 
pins should then be unscrewed, and a dossil of lint placed un- 
der each end of them. The pins should be somewhat curved 
and flattened. 

Different bandages have been devised for the purpose of sup- 
porting the pins and preventing the separation of the adapted 
surfaces. That recommended by Mr. S. Cooper is used as 
follows : A close strong night-cap is provided, with a piece of 
broad tape attached to the back part of it, and with two ends 
of sufficient and equal length. A compress is then to be laid 
over one cheek, and fitted by bringing one portion of the tape 
forward over it, which is to be fastened to the cap on the op- 
posite side of the head. The other compress is then to be 
applied and fixed in a similar manner. Lastly, a bandage is 
to be put under the chin, and brought over each compress up 
to the top of the head, where the ends of it are to be fastened 
24* 



246 DISEASES OP THE LIPS. 

to the cap. During all these proceedings, until the compresses 
are well secured, the assistant must support them steadily with 
his hands. Lastly, the bandage, compresses and cap should 
all be securely stitched together. 

The cut through the lip must be as straight and clear as pos- 
sible, and the operator need not fear to take sufficient of the 
edge to ensure such a surface as will be well coapted. 

When the hare-lip is double, the older surgeons advised to 
perform the operation on one side and then upon the other, but 
this is unnecessary. The edges may be prepared at once, and 
the needles pushed entirely across through the intermediate 
flap. Sometimes a piece of bone projects and pushes out the 
flap. If so, the bony projection must be either reduced by 
compression or cut off. It is always important to save the 
alveolus, and it appears from the practice of Desault and Mr. 
Dunn, that it is seldom necessary to remove it. 

There is often a deficiency of bone, which will cause de- 
formity after the hare-lip has been successfully treated. 

Very often, when the fissure extends along the palate, it will 
be approximated after the closure of the lip; but this is not 
always the case, and articulation and mastication continue to 
be very much interfered with by this unfortunate cleft of the 
palate. 

The dentist can often remedy this serious deformity, by nicely 
adapting a gold plate, so as to form a solid artificial palate, 
which will tolerably well supply the want of the natural one ; 
and this may be considered the most available means of relief 
at our disposal. 

Operations have frequently been performed for the cure of 
this palatine fissure, and sometimes have succeeded. The ope- 
ration, however, is difficult, very painful, considerably danger- 
ous, and very uncertain, and should never be performed except 
by a dexterous and experienced surgeon, and under circum- 
stances in which no artificial means could be used to cover the 
cleft. The design of the operation is precisely the same as in 
the case of that for hare-lip, viz. to cut off the edges of the fis- 
sure and unite them by sutures so as to procure union. 

I will describe this operation in a subsequent chapter. 



DISEASES OF THE LIPS. 247 

The lips being very vascular, abundantly supplied with 
muscles, mucous glands and nerves, are liable to become the 
seat of ulcers and tumors of various kinds. In the male, car- 
cinoma of the lip is perhaps more frequently met with than it is 
in any other part of the body. 

It is not necessary to particularize these affections, nor to 
give a detailed account of their phenomena and treatment. 
They must of course be managed as similar conditions else- 
where, the treatment being modified to suit the exigencies of 
the particular case, and the peculiarities of the location. All 
operations upon these organs must be conducted with great care- 
fulness and nicety, on account of their sensitiveness and vas- 
cularity, and of the deformity and serious inconvenience attend- 
ing any permanent alteration of their relations or structure. Of 
these, adhesion to the gums and contraction of the lips are the 
most common and most serious. 

Adhesion is the result of acute inflammation of the surface 
membrane of the lip and gum, in the course of which plastic 
•lymph is thrown out, and becoming organized, forms a perma- 
nent bond of union between the parts. In all cases of abrasion 
of these surfaces, or of long continued inflammation, care should 
be taken to prevent this accident. It can rarely happen, unless 
the parts thus prepared to unite be pressed together by a ban- 
dage or some similar mechanical application. 

I have seen it, however, result from salivation of a very se- 
vere grade. The cheek, from its less mobility, is more liable 
to this accident than the lips. 

Contraction of the mouth may result from a burn, as may 
also adhesion of the lips to the gums. 

When so serious a deformity has occurred, it can only be 
remedied by an ingenious operation, which, though very pain- 
ful, is generally endured with cheerfulness, so terrible is the 
sense of deformity to most persons, especially to females. 

A few cases will be sufficient to show what has been, and 
what may be done, in unfortunate cases of this kind, and will 
furnish to the ready mind a number of valuable suggestions. 

Simple dilatation of the mouth will be unsuccessful, and 



248 DISEASES OF THE LIPS. 

incision at the commissures will be ineffectual in permanently 
enlarging the orifice, on account of the impracticability of pre- 
venting reunion between the severed portions of the skin. 

In order to obviate this difficulty, the celebrated Dieffenbach, 
who has deservedly obtained a world-wide reputation for his 
success in rhino-plastic* surgery, suggested that a strip of mu- 
cous membrane should be folded over the edge of the incision. 
This fortunate thought has led to a number of brilliant and suc- 
cessful operations for the cure of this class of deformities. The 
following cases are specimens : 

M. H., aged twenty-two, admitted to the hospital under Mr. 
Liston. About a year before, she was knocked down in a 
brawl, and a man jumped upon her, lacerating and bruising her 
cheek and mouth very extensively, and fracturing her jaw. She 
went to St. Thomas Hospital, where her jaw was put up and 
bandaged. These were not removed for some time, and when 
taken off, the wound on the right side of the mouth was found 
to be healed, and the cicatrix considerably contracted. Since 
then the contraction has continued somewhat, and now the 
mouth is so small that she can scarcely get any solid food to 
pass her lips. There is a large and dense white cicatrix on 
the right side of the mouth, rather sharp and puckered toward 
the angle. 

Mr. Liston removed a triangular portion of the cicatrix on 
the right side of the mouth, dissecting it off the mucous mem- 
brane, which was then divided to the extent of the external 
wound. Lint, dipped in cold water, was then laid over the 
surface, to suppress the oozing of blood, which was by no means 
considerable. About five hours after the operation, all oozing 
having ceased, the mucous membrane was turned over the cut 
edge of the cicatrix, and united by three or four points of suture 
to the skin of the cheek; by this means, a mucous surface was 
secured to the newly formed prolabium, and the gradual cica- 
trization and consequent contraction avoided. On the day after 

* Rhino-plastic — literally, nose making. A term first applied to the ope- 
ration for making a substitute for a lost nose, but now applied to all opera- 
tions for restoring lost parts. 



DISEASES OP THE LIPS. 249 

the operation, there was a little swelling around the wound, 
not much pain, and in ten days afterwards the patient was dis- 
charged much relieved. 

Case II. — The daughter of a highly respectable physician, 
when she was eleven years old, was accidentally thrust against 
a heated stove, and her hands, arms, neck and the lower part of 
her face severely burned. 

In spite of all the judicious means employed by the father, 
the wounds about the mouth healed with so much contraction 
that the opening into that cavity was almost obliterated. Her 
father then endeavored to distend the mouth by tents, but these 
accomplished nothing. He then endeavored to enlarge the 
orifice, by making a horizontal incision from each angle of the 
mouth, and preventing the surfaces from uniting, by the inter- 
position of tents ; but this expedient failed also. 

The patient was then brought to Dr. Mutter, who says : 
"When I first saw her, nearly a year had elapsed since the oc- 
currence of the accident. Her appearance at this time was very 
singular. Firm and dense cicatrices nearly surrounded the 
mouth, but were most marked on the lower lip and about the 
angles ; while the orifice of this cavity was barely large enough 
to admit the point of the finger, and presented an oval form. 
The cicatrices of the incision made by her father were also very 
apparent at each angle. The general health was good." 

Dr. Mutter performed upon this young lady the operation as 
proposed by Dieffenbach. 

"The patient was seated in a low chair, with her head sup- 
ported by her father, and exposed to a good light. I then 
introduced the extremity of the fore-finger of my left hand into 
the mouth, and placed it under the left labial angle, which by 
this means was rendered prominent and sufficiently firm to 
permit the second step of the operation to be readily executed. 

"This is accomplished by the introduction of one blade of a 
pair of narrow straight scissors into the substance of the cheek, 
between the mucous membrane and the other tissues, and a little 
above the commissure. The blade is then slowly pushed from 
before backwards, separating, as it passes along, the mucous 



250 DISEASES OF THE LIPS. 

membrane from the muscles and integuments, until its point 
reaches the spot at which we wish to locate the new angle of 
the lips. The blades are then closed, and the parts included 
between them cut squarely and smoothly at a single stroke. 
The first incision being completed, the scissors were withdrawn, 
and a second one, parallel and similar to the first, made in the 
lower lip, the distance between the two being about three lines. 
These incisions were then united at their posterior termination 
by a small crescentic section. 

"By these cuts it is evident that a small strip of muscle and 
integument was insulated from the surrounding parts, and it 
only remained to separate it from the buccal mucous membrane, 
which was easily done by a single stroke of the scissors. 

"The second step of the operation being thus finished on the 
left side, similar incisions were performed on the right. 

"The next steps of the operation, and by far the most difficult 
of the whole, were the division into equal portions, of the mu- 
cous membrane, the eversion of the flaps, and their attachment 
to the edges of the incisions just made, as well as to the red 
pellicle of each margin of the lips. 

"To divide the mucous membrane equally, I separated the 
jaws of the child as much as possible, by which measure the 
membrane was put upon the stretch, and kept sufficiently firm 
to bear the operation of the scissors. The incisions in the 
membrane did not extend as far as those made in the muscles 
and skin, but stopped short about three lines from the union of 
the latter. This was done in order to make the outer portion 
of this tissue adapt itself accurately to the new commissure. 
The flaps were then brought out, reflected over the margins of 
the wounds, and firmly attached to them by means of the twisted 
suture, the needles used being very short and fine. The mem- 
brane must be first attached to the commissure, by which 
measure we secure the proper adaptation of the flaps to the 
other parts. 

"Every thing being thus properly adjusted, a common roller 
bandage was applied, as in cases of fracture of the lower jaw, 
in order to prevent any derangement of the wounds. The pa- 



DISEASES OP THE LIPS. 251 

tient was then placed in bed, with her head elevated, and as 
she had, just before the operation, eaten freely of some light 
food, ordered to take no nourishment of any kind until the next 
visit, and to be perfectly silent." 

Four days after the operation the bandage was removed, and 
the Dr. proceeds : "The sutures, which had been closely bound 
down to the parts by blood, were carefully softened with warm 
water and cut away. As soon as they were removed, the most 
gratifying exhibition of the success of the operation was afford- 
ed. On both sides, union between the everted mucous mem- 
brane and the margins of the wounds had taken place nearly 
throughout, and the new lips presented an appearance almost 
natural. Some of the needles were then removed, but as there 
appeared to be a feebleness in the adhesions at some points, 
the needles passing through them were allowed to remain, and 
a thread cast loosely around them. The bandage around the 
head was also reapplied. 

"Nothing remarkable occurred in the subsequent treatment. 
The dressings were taken off in eighteen days. The mouth 
presented a very good appearance, though the lips were some- 
what thinner than natural, and there was some difficulty in 
bringing them into close contact, especially at the central por- 
tions. I have no doubt, however, but that this defect will soon 
disappear." 

An operation of a similar kind, but much more difficult, per- 
formed by Dr. Hullihen, will be described in a subsequent 
chapter. 



CHAPTER XVIII. 



DISEASES OP THE GLANDS AND GLAND-DUCTS. 

Salivary Tumors. 

Ranula* — This is the name given to a tumor under the 
tongue, which is caused by obstruction of the ducts of the sub- 
lingual gland, and the detention of secretion which conse- 
quently results. 

This swelling is not usually very large, though sufficiently 
so to cause great inconvenience ; but occasionally it has been 
observed of an enormous size. Le Clerc mentions a case in 
which the tumor filled the whole mouth, and pushed forward the 
teeth of both jaws. The patient was nearly suffocated, and 
must have died had he not been relieved by an operation. 

The case related by Boinet to the French Academy, was even 
worse. The swelling not only filled the whole mouth, but 
projected out of it for a considerable distance. The two upper 
incisor teeth on the left side, were lodged in a depression ob- 
servable there, and the canine teeth of the same side, forced 
outwards by the mass of the disease, had pierced the lip near 
the commissure. A fluid, resembling mucus, flowed from a 
narrow aperture at the lower part of the swelling. The tongue 
could not be seen, so much was it pushed backwards, and for 
some time the patient had subsisted only upon liquid food, 
which he was first obliged to convey to the back of his throat 
by some mechanical contrivance. The four incisor teeth, two 
canines and first molars of the lower jaw had been pushed out 
of their sockets by the pressure of the swelling. The pa- 

* Rana — a frog ; so called from a fancied resemblance. 
25 



254 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

tient's aspect was alarming, and he was threatened with 
suffocation. 

Extirpation was thought necessary, and it was performed 
with all due caution. The large cavity thus occasioned, was 
filled with lint. The lower jaw being diseased, Boinet scraped 
some of its surface off, and covered the places with lint, either 
dry or dipped in spirit of wine. Some exfoliations followed, 
and the fungous granulations which grew, were suppressed with 
proper applications. In three months the cure was completed.* 

Ranula may readily be detected. It presents itself in the 
form of a rounded or oval, soft, semi-transparent tumor, on one 
or both sides of the frenum linguae. It is not painful, and oc- 
casions little inconvenience until its volume becomes sufficiently 
great to interfere with the movements of the tongue. 

Nevertheless, encysted tumors of various kinds do sometimes 
occur in this locality, and have frequently been mistaken for 
ranula. 

Simply to open the tumor and let out the fluid contents, will 
not cure the disease, inasmuch as the obstruction of the ducts 
will continue. It becomes necessary, therefore, to reopen these, 
or, if this cannot be done, to make an artificial opening, which 
may permit the secretion of the gland to escape. 

Lewis advised the introduction of small leaden stilets to dilate 
the canal, and permitting them to remain for a day or two at a 
time. Dr. Physic and others preferred the passage of a thread 
through the tumor, which was permitted to remain as a seton. 
Dr. Reese considers this plan infallible, or nearly so. 

The method pursued by Lewis, and followed by Dr. Mutter, 
is to make an oval or round incision, and then to touch the 
margin with nitrate of silver, so as to create an artificial fistula. 

Sometimes all other means fail, and it is necessary to dissect 
out the whole tumid mass. 

The salivary glands are sometimes the seat of tumors of a 
more formidable character. Being enclosed, the sublingual 
gland especially, by the muscles of the throat and tongue, these 
tumors, even if suppuration takes place, cannot commonly be 

* Cooper's Surg. Diet. — Art. Ranula. 



DISEASES OP THE GLANDS AND GLAND-DUCTS. 255 

relieved by the discharge of the contained matter. The sac 
may be repeatedly punctured without relief, for the fluid con- 
tinues to form, and repeated wounds result in thickening and 
enlargement of the gland, and finally a solid tumor is formed, 
which may go on to enlarge until it may cause suffocation. 

The case of Margaret Murray, so graphically related by Mr. 
John Bell, should warn us against trifling with even apparently 
trivial tumors of these parts, and dentists, as they may be the 
first to observe, should be prepared to distinguish these swell- 
ings, and advise that prompt and decided treatment which is 
so important in these cases. In the case of Margaret Murray, 
the tumor was as large as the patient's head, and ^threatened 
imminent suffocation. In fact, the poor woman lived in a state 
of semi-strangulation. When upon the verge of gangrene, the 
tumor, which was hard upon the surface but fluctuating beneath, 
was transfixed with a trocar. About two pounds of thick ropy 
matter was discharged. It was hoped that this discharge would 
afford relief; but, as Mr. Bell very justly observes, those who 
indulged such an expectation did not recollect that to produce 
a secretion so profuse, a great mass of vascular substance is 
required, and the consequence of permitting a gelatinous col- 
lection of matter to attain to such a size is, that the vessels by 
which it is secreted, not being, as in a case of suppuration, 
ulcerated or destroyed, the basis, consisting of these vessels, is 
consolidated into a tumor. The sac may be emptied, but the 
nucleus to the sac cannot be discussed, but hardens and inflames 
pari passu with the evacuations. 

In the case of this poor woman, though the salivary matte** 
continued to run, thin and pellucid, through the opening, the 
tumor did not diminish. "She lay reclined, always struggling 
for breath, and sometimes attacked with violent asthmatic 
paroxysms; the jaws almost entirely closed, the mouth con- 
tinually open ; the nostrils dilated, and the stupor, which 
such difficulty of breathing causes, increasing every moment; 
and her swallowing being equally difficult with her breathing, 
she expired in the fourth week." 

Although tumors of this kind may contain thin matter, a 



256 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

mere puncture is not sufficient for their relief. A free incision 
must be made, laying open the diseased gland, and the treat- 
ment directed to the permanent adhesion of the walls of the 
sac. The sooner this is done the better. 

Tumors of the Submaxillary Gland. 

This gland is very subject to inflammatory swellings, which 
frequently become indolent 3 and remain for a long time without 
causing inconvenience. Occasionally, however, it is the seat 
of very dangerous and even fatal tumors. 

Mr. John Bell records the case of "Jenny Brown, a poor 
solitary thing, who worked laboriously to maintain her aged 
mother, her father being for some years dead. She slaved at 
all kinds of work, as an out-servant in a farm yard. After 
churning milk, being exceedingly heated, she went out with 
her cap loose and her jaws exposed, and by carrying bundles 
of wet grass for the cows upon her head, had a severe tooth- 
ache, for which a tooth was pulled; and still continuing in the 
same labor, she got cold. Thence arose a kernel-like swelling 
of a gland under the lower jaw, near the gum of the corrupted 
tooth. Her face was swelled so that her eyes were closed ; the 
lump grew as big as a hen's egg, with severe pain ; the swell- 
ing of the face subsided, the pain ceased, but the glandular 
tumor remained. Such was the slight beginning of the dis- 
ease." The tumor, however, continued to enlarge until it be- 
came necessary to extirpate it. This was attempted in an 
awkward and irresolute way, and abandoned in the midst of the 
operation. "One advantage this poor creature derived from 
this unsuccessful operation, viz. the relief from pain, for she 
was relieved by the loss of blood, insomuch that she recovered 
her health, and in some degree her strength, and returned to 
work for the support of her old mother : at least she could 
spin. For a long time she has been unequal even to this. She 
has lingered and wasted in a very helpless condition, and is 
now in a state of extreme weakness from want of food. She 
walks but a few paces without stopping for want of breath ; 



DISEASES OP THE GLANDS AND GLAXD-DUCTS. 257 

her swallowing is difficult ; she has great pain, night and day, 
from the mere distension and size of the tumor. The weight 
of it is intolerable, and it appears to me that in not many weeks 
she must be relieved from her sufferings." 

The suffering of the patient seemed to be occasioned by the 
great bulk of the tumor pressing upon the trachea, and even 
the breast, and embarrassing respiration. The tumor had 
every character of what is usually called a wen; the whole 
mass incredibly heavy in proportion to its bulk, so that she 
supported it continually with a sling round the head and neck. 
It was extremely firm, not very vascular throughout its sub- 
stance, but receiving its arteries at particular points. It had 
no great veins running over its surface, whence Mr. Bell pre- 
sumed that it had nothing of a cancerous character or irritated 
circulation. 

Mr. Bell wished to operate, but was over-ruled. 

Some remarks of Mr. Bell, in lecturing upon these subjects, 
are so judicious, that I cannot refrain from quoting his language 
at some length. 

"But it is. not the discussing of interesting doubts and ques- 
tions of life and death, nor the performing operations within 
the limits of possible success or possible safety, that constitute 
the chief occupation of one engaged in practice. The more 
homely talent of distinguishing the various aspects and charac- 
ters of tumors, and treating them judiciously, is far more de- 
sirable to acquire; and, indeed, there is a very perplexing variety 
of tumors within the mouth and around the jaws, which one 
learns to distinguish only by referring their various aspects to 
corresponding peculiarities in the structure of the parts. The 
tumors which I have just described are of a very malignant 
character, and I confess I know not whether to refer them to 
the salivary or the lymphatic glands ; to the latter, rather, 
I believe. This, for example, of Mr. M., though it looks 
like a tumor of the submaxillary gland, which holds im- 
bedded, I may say, in its substance, the facial artery, it could 
not have been extirpated without dividing that artery. The 
submaxillary gland is divided into two masses, and the trunk 
25* 



258 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

of this artery is received into the recess or cleft. The artery 
seems to twist round the gland, and I have, both in extirpating 
the submaxillary gland and in assisting at such operations, 
recognized it by this mark. 

"The following case, if not full of interesting particulars, is 
at least accompanied with useful rules, and I transcribe them 
from my case- book, with those reflections which arose in my 
mind when forming my opinion and preparing for the operation, 
as I have ever done, with a scrupulous and conscientious desire 
to foresee every eventual danger, and recollect every circum- 
stance, anatomical or pathological, which might contribute to 
my patient's good ; the reflections, you will perceive, have a 
mutual relation to the instruction of my pupils and my own 
improvement. 

"It is the case of a young lady, who came from a very great 
distance, urged by her own fears and the persuasion of her 
surgeon. 

"First, I observe that the gland affected, seems to be the very 
gland which, after an unsuccessful operation, grew to so im- 
mense a size in the case of Jenny Brown, and in her, though 
the tumor arose from the slightest and most accidental cause, 
(extraction of a tooth,) without any cancerous diathesis, or 
other malignant tendency, it proved fatal by suffocation. What 
might have become of this lady, it is easy to foresee, had she 
not been warned by her surgeon, and alarmed by the recent 
accession of pain, for her own safety. 

"Secondly, when we are consulted what is to be done in 
any particular case, we are, in other terms, called on to prog- 
nosticate what will be the patient's condition at the distance of 
one or two years. In the present case, the gland is very large, 
and of a stony hardness. It never can suppurate; it is even 
threatened with a cancerous inflammation; it is indeed incapa- 
ble of any other. The pain requires that something should be 
done, and our prognostics may be safely grounded on this un- 
questionable assumption, that such a tumor will not fail to grow, 
and that, in one or two years, the deformity and bulk will of 
itself be a motive, while the suffocating condition of the patient 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 259 

will be an absolute reason for operating, however dangerous 
the operation may be rendered by such unwise delay. It is 
moreover to be observed, that this gland is the submaxillary 
gland, which has the facial artery niched in between its two 
lobes, not so inextricably, indeed, as the parotid is connected 
with the carotid artery, but in a degree to give trouble to the 
surgeon, and accompanied with a degree of danger, in the case 
of operation, which is well worth calculating. 

"Thirdly, we are to regard the actual circumstances of every 
patient as a part of his case, and the danger to this lady, if re- 
manded to her own country, so far distant and so difficult of 
access, is but too palpable. Should we speak to her the usual 
temporising language, and say, 'It will perhaps get well; a 
slight course of mercury or cicuta may be useful, and time may 
do much; perhaps it may be well to wait;' it may happen that 
the gland may become stationary in its growth. A mercurial 
course may be of use, but I fear that this is, in the truest sense, 
tampering with a tumor, and that time can do nothing but in- 
crease the danger. 

"It seems to me but too possible that this lady, before she 
can take a second resolution and accomplish a second journey, 
will be suffocating and in immediate danger of death. Then 
we should not venture to do that operation which is now com- 
paratively easy ; for this gland being seated in the angle be- 
twixt the trunk of the carotid artery and its first great branch, 
the maxillary or facial, will distend that angle, and both the 
trunk and its branch will be too closely united with the tumor 
to admit of operation, or will make the operation most danger- 
ous and critical. 

"Fourthly, though there is no imminent danger in the pro- 
posed operation, the circumctances are sufficiently forbidding 
to make it far from being a matter of choice. My assistant 
was unwilling that it should be performed without the advice 
of Dr. Munroe, and his assent seemed rather reluctant. The 
tumor is of a very considerable size ; it is plainly the submaxil- 
lary gland, as may be inferred from its shape, size and peculiar 
hardness; not a lymphatic gland, for then, most likely, more 



260 DISEASES OP THE GLANDS AND GLAND-DUCTS. 

than one would be enlarged. We must be resolved to deal 
with the artery in one of two ways : either to dissect it so from 
the tumor as to insulate the artery, and turn the tumor from 
under it; or, should this attempt threaten to embarrass our 
operation, to cut it across where it lies over the middle of the 
tumor, tying before dividing it, lest it should shrink back to- 
wards its trunk. No one circumstance is so favorable to the 
operation as that extreme hardness of the tumor which makes 
the operation necessary, for that shows it to be circumscribed, 
and to be little connected by inflammation with the cellular 
substance. 

"Notes of the Operation. 

"We had agreed either to dissect so as to lay the artery on 
one side while employed in extirpating the gland, or to tie and 
cut across, and so proceed with greater freedom in the more 
dangerous part of the dissection; but after the first incision, 
which I made according to the length of the jaw-bone, the in- 
cision being long and more free, the several parts appeared in 
so advantageous a state as to leave no doubt nor difficulty in 
the rest of our proceedings. 

"The artery presented itself arching over the diseased gland, 
much elongated and serpentine, so that in place of embarrassing 
the operation with any needless delicacy, or endangering the 
shrinking up of such an artery towards its trunk, we passed 
two ligatures of single thread under it, cut betwixt the liga- 
tures, and then proceeded more confidently in extirpating the 
gland. There we found no such adhesion of it to the trunk, 
or rather to the sheath of the carotid, as we had reason to ap- 
prehend. The tumor was of such a stony hardness, the cellu- 
lar substance so loose, the arteries so disengaged from it, that 
without the help of the knife, with only the swallow-tailed end 
of its handle, which I used as a scalpel, I turned out the tumor 
in a few seconds, and the tumor carrying its cellular substance 
along with it, the styloid muscles were left as clear, distinct and 
bare as after a neat dissection upon the dead subject." 



DISEASES OP THE GLANDS AND GLAND-DUCTS. 261 

"Case II. * — A young woman of Berwick, whose native 
peculiarity of accent had got a singular aggravation by such an 
uncouth obliquity and imperfect motion of the tongue, as con- 
veyed the notion of her attempting to chew and turn each voca- 
ble with her tongue before she proceeded to swallow it, in place 
of uttering it. 

"This was produced by a tumor of very great size, and of an 
appearance so peculiar as plainly to denote its character. It 
consisted in a vast collection of matter in the sublingual gland, 
and as that gland is covered by the whole thickness of the 
tongue within, and by the mylo-hyoidcei muscles without, and 
bounded by the line of the jaw-bone, it had the following 
singularities of character: It could not be distinguished as a 
tumor, but had rather the appearance of a general swelling of the 
lower part of the face, jaw and neck, such as often accompanies 
severe tooth-ache or mumps. Upon laying the hand upon the 
outside of the neck, below the lower jaw-bone, the whole hand 
was filled with a swelling, apparently solid, but so little convex 
or circumscribed as to resemble in no degree the tumor of any 
particular gland, and yet so limited and so firm as not at all to 
resemble the general tumefaction proceeding from tooth-ache. 
Upon introducing the finger into the mouth, you found the 
tongue raised, turned edge uppermost, and pressed entirely 
towards the left side of the mouth, the external tumor being 
upon the right side. Upon pressing the fingers very firmly 
down by the side of the tongue, and reaching from without, you 
could sensibly perceive not so properly a fluctuation as an 
elasticity, which implied the presence of a fluid; the tumor 
seemed elastic like a foot-ball, but with a degree of tension 
which made it seem almost solid. It was by comparing a va- 
riety of circumstances, especially the original place and slow 
growth of the tumor, that I confidently referred it to the sub- 
lingual gland. In this I had the advantage of the surgeon un- 
der whose particular care she was, but I did him the justice to 
send her back to him, again and again, expressing my opinion 

* Principles of Surgery, by John Bell, edited by Charles Bell. 



262 DISEASES OP THE GLANDS AND GLAND-DUCTS. 

and my wish at the same time, that he should do whatever he 
might suppose right. By good fortune, she called upon me the 
day she was to return home, nothing being as yet done to the 
tumor, but supplied with abundance of blisters and plasters to 
apply at a fit opportunity to her throat. I felt now that pro- 
fessional ceremonies should give way to essential charities. I 
placed her in a chair, and almost without her consciousness, at 
least before she was aware, I struck a fine bleeding lancet deep 
into the tumor by the side of the frenum of the tongue, when, 
from the firm compression of the surrounding parts, the matter, 
though too gross to pass freely through such an opening, was 
spewed out from the orifice, in a manner expressly resembling 
that in which yellow paint is squeezed out from the bladder 
upon a painter's pallet. It was of a deep saffron color, thicker 
than mustard, mixed like gruel with seed-like particles, and 
exceedingly fetid. I knew that the tumor was not emptied, 
though the outward swelling was almost gone, but I also knew 
that though I should not enlarge the opening, the second secre- 
tion from the surface of the sac, which is in all cases thin, 
would dilute and wash out whatever viscid matter remained ; 
and when she saw how suddenly my prognostic was fulfilled, 
she expressed a perfect confidence in whatever I predicted, 
and a perfect willingness to submit cheerfully to whatever I 
proposed to do. Next day I introduced the point of a probe- 
pointed bistoury into the orifice made by the lancet, and know- 
ing that the lingual artery lies on a lower level, imbedded among 
the muscles, and running along the lower surface of the tumor, 
while I had over the point and blade of my bistoury nothing 
but the inside membrane of the mouth, much thickened, I run 
it fearlessly and at one stroke, as the less painful way, along 
the whole length of the tumor, when the thickest of the yellow 
mucus flowed freely or was raked out with the points of the 
fingers and the handle of the bistoury ; and the tongue de- 
scended now to its natural level, was in a capacity once more 
of delivering the peculiar dialect of her native city in all its 
purity. 

"So tense and apparently solid was this tumor, in conse- 



DISEASES OP THE GLANDS AND GLAND-DUCTS. 263 

quence of the compression by so many surrounding muscles, 
that her surgeon mistook it for a solid and strumous swelling. 
I reckoned that in this, as in all cases of sacculated tumor, the 
second secretion, which was thinner, would wash out the thicker 
mucus, and I was not deceived ; but she left me too early for 
me to witness the obliteration of the sac. 

"I find it, in all such cases, a matter of some importance, 
especially in a girl, to anticipate the outward suppuration of 
any sacculated tumor, by puncturing it, though to a great 
depth within the mouth and under the tongue, and equally ne- 
cessary to be at pains in preserving the opening and obliterating 
the sac ; a slight misconduct in this respect occasions much 
distress to the patient, and much superfluous labor to the sur- 
geon. Among the examples of this which I have had occasion 
to remark, the following is the most instructive. 

"Case III. — The case of Peggy Hall represents a tumor, 
which in all its stages, and for a course of three years, was ill 
understood and worse treated. She was a stout and lusty girl, 
about twenty-two years of age. The tumor occupied all the 
left side of the neck, from the lobe of the ear and angle of the 
jaw, quite to the sternum, displacing the mastoid muscle. This, 
like the tumor of Jenny Brown, arose from that slight inflam- 
mation which follows the extraction of a tooth. More than two 
years ago, after being distracted with tooth-ache, she had two 
carious teeth pulled from the lower jaw, and she distinctly re- 
remembers that two days after the extraction of the sound tooth 
she was sensible, upon undoing the flannels in which her 
swollen and inflamed face had been for some time wrapped up, 
that there was a little lump about the size of a small plum. It 
lay under the angle of the jaw, and had never ceased to grow, 
and has now, without the slightest pain or change of color, at- 
tained the present size. In the month of April, 1799, she was 
directed to apply some kind of plaster. In May, Dr. Monroe 
advised her to have it opened. In a few weeks after, this was 
attempted by the surgeon of the village in which she lived, who 
made a large incision, but being soon alarmed, he laid aside 
the knife and lancet, and prosecuted his work rather by boring 



264 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

than by cutting. He tried, with probes and directors, to make 
good his way into the sac, but having pushed them very deep, 
and toiled half an hour in vain, he abandoned his purpose. 

"The tumor was distinctly a great sac of fluid secretion. 
There was nothing doubtful in the case. The sac lies under 
the platysma myoides, and under and before the mastoid mus- 
cle. The belly of the mastoid being raised Upon the bag or 
tumor, feels soft and flaccid, and might have seemed to an un- 
skilful surgeon to form a part of the tumor. By making his 
incisions over the belly of the muscle, he could not penetrate 
to the sac otherwise than through the body of the mastoid 
muscle. Having cut to a considerable depth among solid and 
quivering flesh, he became alarmed. Willing still to penetrate 
farther, and yet without danger, he bored with his finger, cut a 
little obliquely with his knife, and bored a little more with his 
directory, till, having buried it apparently in the tumor, to the 
depth of three or four inches, he believed, and to the ignorant 
relatives and patient seemed to prove, that there was no fluid 
in the tumor, while there was nothing singular in all this but 
his own awkwardness. He had penetrated entirely under the 
belly of the mastoid muscle, pushing his probes obliquely be- 
tween it and the sac. To avoid the great vessels of the neck, 
he wrought obliquely backwards, and by cutting obliquely 
backwards, he made good his way under the belly of the mas- 
toid muscle. 

"The young woman endured the disappointment and suffer- 
ed the tumor still to extend, not without great inconvenience 
and deformity, for seven or eight months, the operation being 
then performed more correctly and confidently. Every circum- 
stance tended to confirm the notions I had formed of this awk- 
ward proceeding. The surgeon who now operated was timid 
and careless in conducting the cure. 

"The incision through the skin only was freely made. The 
incisions through the platysma myoides were made timidly, the 
flesh of its fibres retracting and quivering as they were cut. 
The sac then burst from betwixt the divided fibres of the mus- 
cle, white and transparent. Upon this being divided, several 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 265 

pounds of thin serous fluid gushed out. Then the long iron 
probe was passed across the cavity of the tumor, and its point 
cut upon at the anterior edge of the mastoid muscle; in short, 
near the place of the former incisions; whereas, to lie across 
the tumor, the point should have been cut out behind the belly 
of the mastoid, and then the seton or cord would have more 
effectually inflamed the sac and obliterated the cavity. 

"But this girl was doomed still to suffer from timid practice. 
The seton ill introduced at first, was worse managed. In what- 
ever way introduced, it should have been made to obliterate 
the sac. The sac was permitted to remain always half full ; 
its walls were never brought together so as to favor their ad- 
hesion ; the cord was even withdrawn and the orifice permitted 
to heal; the fluid again collected to the amount of two pounds; 
it was again evacuated by freeing the old opening, slitting up 
a part of the muscular sac with a probe bistoury, and oblite- 
rating it, (a purpose which was very slowly accomplished,) by 
strong injections of port wine and stimulating medicines. 

"The case of this girl, which was protracted by unskilful 
treatment to six months, should have been accomplished in three 
weeks, and while the sac was pouring out matter from its 
thickened walls, and hardening into a solid tumor under the 
jaw, the girl was in danger of having established an incurable 
and growing disease ; for a tumor so situated, and proceeding 
from such a cause, could never, by the most dexterous opera- 
tor, have been dissected away from the neck and jaws." 

I have felt no hesitation in quoting at length the preceding 
narratives of cases, and the excellent remarks attending them. 
Facts like these impress the mind of the reader much more for- 
cibly and permanently than dogmas. In the instances above 
cited, we see what serious consequences to the glands of the 
mouth may be occasioned by the operation, to which every 
man thinks himself competent — the extraction of a tooth; and 
we also see how very important it is to be able to detect the 
nature of the disease in its earliest manifestation, and to apply 
the bold prompt remedy which only can prevent the threatened 
mischief. 
26 



266 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

Certainly, if the dentist, however careful, may be the unfor- 
tunate agent to produce such tumors, he ought at least to be 
prepared to do all that skill can do to remove them. 

Tumors of the Parotid Gland. 

The parotid is the greatest of the salivary glands, and fur- 
nishes the largest part of the saliva. It is situated in the irregular 
cavity bounded by the ramus of the lower jaw and the mastoid 
process of the temporal bone, penetrating as deeply back as the 
styloid process, and even dipping behind it. It extends from 
the zygoma to the angle of the jaw, and from the meatus ex- 
ternus and mastoid process to the masseter muscle. This gland 
is subject to ordinary inflammatory swelling from cold, and es- 
pecially to a peculiar specific inflammation called cynanche 
parotidea, or vulgarly, mumps. 

The parotid is also sometimes the seat of carcinomatous dis- 
ease, and may be affected by all the modes of disorganization 
which affect glandular structures. 

The position of this gland, and its vascular and nervous 
connections, render its extirpation one of the most difficult 
operations in surgery. Until recently, the complete extirpation 
was considered impracticable, and even now many doubt that 
it has ever been effected. Allen Burns, Boyer, Richerand and 
other celebrated anatomists and surgeons declared that the safe 
extirpation of the whole parotid was impossible, but there can 
be no reasonable ground for rejecting the testimony of the dis- 
tinguished and honorable men who claim to have succeeded in 
the operation. 

The credit of having first demonstrated the practicability of 
this operation by actually performing it, seems to be due to 
Prof. Samuel White, of Hudson, N. Y., who extirpated the en- 
tire gland, for a carcinomatous tumor, in the year 1808. 

Notwithstanding that the patient was examined by expe- 
rienced surgeons, who satisfied themselves of the fact of the 
complete extirpation, the operation was not attempted in Europe 
until 1823. It has since been performed repeatedly on both 
sides of the Atlantic. 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 267 

As the result of the testimony now submitted to the profes- 
sion, it is sufficiently determined : 

1st. That the exsection of the parotid, though an exceedingly 
difficult, is, in the hands of a good anatomist and skilful sur- 
geon, a feasible operation. 

2d. That the carotid artery and its larger branches are ne- 
cessarily implicated in the operation. 

3d. That it is impossible to spare the facial nerve, and con- 
sequently paralysis is an inevitable result of the operation.* 

I think it unnecessary to give any directions, gathered from 
the experience of the most successful operators, for the per- 
formance of so very delicate and dangerous an operation as the 
extirpation of the parotid. No sane man will attempt it unless 
perfectly acquainted with the anatomy of the parts, and as 
familiar as reading can make him with the history of previous 
operations. To one thus prepared, there needs but the bold 
heart and expert hand to secure at least the utmost likelihood 
of success which the character of the operation will admit. 
There are no men whose habits of operating beget more facility 
in manipulating, more nice manual dexterity, than dentists, and 
if they will acquire the necessary information, they may become 
the most expert of operators. The example of Dr. S. P. Hul- 
lihen, of Wheeling, is worthy the imitation of all who would 
be scientific dental surgeons. 

Salivary Fistula. 

The duct of the parotid gland, called the duct of Steno, 
emerges at the upper extremity of the middle third of the ante- 
rior edge of the gland, and proceeds forward and inward, 
directly under the skin, and on the masseter muscle. It is dis- 
tant from three to five lines from the lower edge of the zygoma. 
It passes on the anterior edge of the masseter muscle, pene- 
trates between the fibres of the buccinator muscle, and opens in 
the lateral walls of the cavity of the mouth opposite the first 

# Cooper's Surg. Diet., by Reese. 



268 DISEASES OF THE GLANDS AND GLAND-DUCTS. 

posterior molar tooth of the upper jaw according to Meckel, 
the second molar according to Harris, and the second and third 
bicuspis according to Cooper — the situation of the opening 
differing somewhat in different subjects. 

This duct, being very superficially situated, is exposed to 
injury, and is often wounded by an incautious operator, or by a 
a blow. Sometimes, also, the duct may be obstructed by the 
pressure of a tumor or by inflammation. In such cases the sa- 
liva will accumulate until it makes a passage through the cheek, 
and continuing to pass through the opening, will form a per- 
manent opening, which is called salivary fistula. 

The discharge of the saliva over the cheek is very annoying, 
and the artificial opening is a very serious deformity. 

A variety of methods have been employed to cure salivary 
fistula. Monro inserted a seton from the external fistulous 
opening into the mouth, and kept it there until a new fistula, 
open both on the cheek and in the mouth, had been fully form- 
ed. He then destroyed the edges of the external opening with 
lunar caustic, and caused adhesion between the new surfaces 
produced by the sloughing of the superficial eschar. The saliva 
of course continued to flow through the fistulous channel into 
the mouth. 

Desault also employed a seton, but he introduced it through 
a canula, as follows : Placing two fingers of his left hand into 
the patient's mouth, and placing them between the teeth and 
cheek opposite the fistula, he introduced a small hydrocele 
trocar in its canula, through the cheek, just before the opening 
of the posterior part of the duct, and in a direction inclined a 
little forward. An assistant now took hold of the canula, while 
Dessault withdrew the perforator and passed a line of thread 
through the tube into the cavity of the mouth. The canula 
was then taken out, and a seton, which was then fastened to 
the end of the thread in the mouth, was drawn from within 
outwards, but not so far as to come between the edges of the 
external opening, where the thread alone lodged, and this was 
fastened with sticking plaster to the outside of the cheek. The 
outer wound was dressed with lint and compresses. Dessault 



DISEASES OF THE GLANDS AND GLAND-DUCTS. 269 

used to change the seton daily, introducing regularly rather a 
larger one, and always taking particular pains not to permit it 
to pass between the edges of the external opening. 

The patient was enjoined to use the jaw as little as possible, 
and for some time confined to liquid food. In about six weeks 
he omitted the seton, leaving in the thread for a little while 
longer. This being taken away, he completed the cure by 
touching the little aperture remaining, with caustic. Beclard 
succeeded several times, by passing a leaden stilet from the 
inner surface of the cheek into the duct, at the point where it 
was obstructed. He then made a fresh incised wound of the 
external fistulous opening, and closed it with the twisted suture. 

Mr. Samuel Cooper prefers the operation of Beclard, when 
possible, as causing a more speedy cure. 



26* 



CHAPTER XIX. 

TUMORS REQUIRING AMPUTATION OP A PART OR THE WHOLE 
OF THE UPPER JAW. 

The superior maxillary bone is frequently the seat of tumors, 
which, from their enlargement, interfere with the functions of 
speech, deglutition and respiration, and often prove fatal. 

Some of these tumors are of the malignant fungus variety. 
These, commonly, are seated in the antrum. The first indica- 
tion of their presence is an aching of the face, which is usually 
attributed to tooth-ache, but which continues and aggravates, 
notwithstanding all the efforts to alleviate it. The jaw rapidly 
swells, and the nostril of the affected side is soon obstructed to 
respiration, and discharges matter. The walls of the antrum 
are soft, and yield readily to pressure. The nostril is filled 
with a bleeding tumor. The disease rapidly progresses — finds 
its way into the throat, detaches and pushes forward the teeth, 
throws out an enormous fungus into the mouth or on the cheek, 
hectic and emaciation rapidly reduce the patient, and he soon 
succumbs to aggravated suffering. 

With such a disease as this, we have no means of contending. 
An operation would be worse than useless. Fortunately, its 
progress is rapid, and death speedily brings the ardently desired 
relief. 

There is another form of tumor, which commences in the pe- 
riosteum and bone, often from some accident, as a blow or fall. 
This tumor is of slow growth, and is solid and resisting. It is 
little sensitive, does not bleed, nor involve surrounding tissues 
except mechanically by its growth. In short, it is a tumor of 
the benign kind, not connected with constitutional disease, and 
it may be removed with entire safety. 



272 TUMORS REQUIRING AMPUTATION. 

In proceeding to remove a tumor of this kind, involving the 
superior maxillary, the surgeon must have in view, 1st. To take 
away every portion of the disease; and 2dly. To cause as little 
deformity as possible. The tumor should be got out whole ; 
any incision into it would probably induce an embarrassing 
hemorrhage. 

The operation itself is by no means dangerous, as compared 
with other amputations, and it may be performed without much 
difficulty, by a dexterous and confident surgeon. 

Mr. Liston's directions for performing the operation are as 
follows : "Having to work among bones, you must use a good 
strong and broad knife — one with which you can make free 
and proper incisions. To uncover a very large tumor, you may 
make one incision from the point of the cheek-bone to the cor- 
ner of the mouth, carrying it outwards also in the direction of 
the zygoma : another from the angle of the eye to the middle 
of the upper lip. The mark of these incisions must always be 
more or less apparent. But if you have a tumor of moderate 
size to deal with, you should make one incision from the angle 
of the eye, down the side of the nose, bring it under the alse, 
and cut away the alae from the edge of the superior maxil- 
lary bone; then you bring the cut down well towards the co- 
lumna nasi, push the knife through the lip, and cut right down 
the median line. A scar from that incision will scarcely be 
perceived if the parts are cleverly and carefully put together. 

You make another and much less extensive incision from the 
same point, in the course of the fibres of the orbicularis palpe- 
brarum, out towards the zygoma, carrying the knife under the 
eye; you can then turn downwards and outwards a large flap, 
uncover the tumor, and get to the processes of the bones. These 
being divided, the tumor almost tumbles out. 

Before commencing your incision, or after you have turned 
the flap back, .you may require to take out one tooth, and you 
remove the lateral incisor. You must be provided with strong 
edged cutting forceps for dividing the bones, and very strong 
scissors for separating longitudinally the palatine arch. Before 
applying them, you cut a notch out of the alveolar process of 



TUMORS REQUIRING AMPUTATION. 273 

the tooth removed, with the point of the cutting forceps. Very 
often you are compelled to take away the os mala, or perhaps 
you may saw it through. Supposing that you are going to 
take away the os mala by the forceps, you divide the zygomatic 
arch and also the junction of this bone with the frontal bone, at 
the transverse facial suture. You cut the nasal process of the 
maxillary bone ; then putting one blade of the scissors into the 
nostril, and the other into the mouth, cut down and you have 
destroyed all the attachments of the tumor. You must next 
carefully detach the parts with the orbit, cutting the superior 
maxillary nerve far back; that must not be drawn out from its 
origin; then putting your finger on the tumor, you detach with 
your knife any remaining connections, and out tumbles the 
mass. You will be astonished to find how little blood follows 
an operation of this kind ; it can be done in a very few minutes. 
There is seldom any necessity for stopping the bleeding tem- 
porarily by pressure on the carotid; after you have turned the 
tumor out, perhaps you will not find a single vessel to tie, or 
only one. You take hold of that with the fingers, put on a 
ligature, and then lay the flap down. The tumors should come 
out quite entire, and after stopping any vessel that may bleed, 
you put a dossil of lint into the cavity, bring over the flap, and 
put the parts neatly together. 

"You introduce some -points of interrupted suture under 
the eye and by the side of the nose ; you attach the alae, and 
then put two points of twisted suture into the upper lip. In a 
short time the cavity fills up, and it is altogether an exceedingly 
satisfactory operation. I have extirpated the upper jaw to re- 
move fibrous tumors, nine or ten times, without the loss of a 
single patient. It is an operation more successful than the 
amputation of the leg, or, at all events, of the thigh, and is 
attended with as little risk." 

AMPUTATION OF THE LOWER JAW. 

The lower jaw is also sometimes the seat of tumors which 
may, like those of the upper maxillary, require the use of the 
knife. 



274 TUMORS REQUIRING AMPUTATION. 

These tumors sometimes consist of a deposit of a glairy fluid 
between the plates of the bone, gradually distending it ; some- 
times they are malignant, at others they consist of cartilage and 
bone. 

Portions of the lower jaw have very frequently been taken 
away, and sometimes with but little difficulty. It occasionally 
happens, however, that a very large portion, even the whole, 
requires to be removed. 

In exsecting a portion of the lower jaw, it is very important 
to avoid unnecessary disfiguration, and our ingenious country- 
man, Dr. Rhea Barton, has made an excellent suggestion on 
this point. 

It is to preserve a rim or margin of the bone, so as to pre- 
serve the outline of the face, and afford a base for the insertion 
of false gums or teeth. In all cases where the extent of the 
the disease will permit, this should be done, as the rim of bone 
thus preserved will be of immense use to the patient. 

The incision through the soft parts should be made beneath 
the base of the jaw, so as to hide the cicatrix as much as possible. 

Prof. Mutter has succeeded in detaching a tumor with a por- 
tion of the jaw, without any external incision or deformity 
whatever. This tumor was seated upon the symphysis and 
two-thirds of the left ramus of the bone. The patient being 
seated, with her head supported by an assistant, the tumor was 
laid bare in its whole extent, by detaching the lip and integu- 
ments of the chin and cheek from the adjacent bones. No ex- 
ternal incision was made, yet Dr. M. had no difficulty in turning 
the soft parts down under the bone, so as to leave its base per- 
fectly visible. Next, partly with a saw and partly with a strong 
scalpel, he cut through the base of the tumor, leaving a small 
rim of the bone, composed of the rounded portion of the lower 
jaw. Two perpendicular cuts were then made, (one on each 
side of the mass,) with the cutting forceps — and the tumor, thus 
loosened, was readily removed with a few strokes of the scalpel. 
As the hemorrhage was profuse, the actual cautery and pledgets 
of lint steeped in creosote were applied, and with entire suc- 
cess. The lip was then brought back to its original position, 



TUMORS REQUIRING AMPUTATION. 275 

and cold water dressing applied to the face. A perfect cure, 
without the slightest deformity, was accomplished in two weeks. 
To our countryman, Dr. Mott, is due the honor of having 
first attempted, and executed successfully, the amputation of 
the lower jaw at the articulation ; after him, Mr. Cusack, of 
Dublin, performed it. According to a note by Dr. Reese, in 
Cooper's Surgical Dictionary, the operation had not been per- 
formed by any others up to 1842. Mr. Liston, in his lectures 
delivered in 1844, speaks rather sneeringly about the "fuss" 
made about extirpating the jaw, and gives the credit of the 
operation to Mr. Cusack, of Dublin. He then proceeds to 
describe it as though it had been an every day operation with 
him. This conduct of Mr. Liston is remarkable enough, but 
it is more strange that his editor, Prof. Mutter, has not corrected 
the error, and done justice to Dr. Mott. 

The operation is one of the utmost difficulty, and it is use- 
less to give any directions for its performance. None but a 
surgeon of well tried skill would be justifiable in undertaking 
it, and such a one would pay but little attention to directions. 
These of Mr. Liston may be well enough, but we do not know 
that he ever performed the operation on a living body. 

Dr. S. P. Hullihen, a practising surgeon dentist, of Wheel- 
ing, and one of the best surgical operators in this country, has 
performed an operation upon the jaw, which well deserves to 
be recorded here. As Dr. Harris justly remarks, "the ingenu- 
ity, skill and boldness displayed in the conception and perform- 
ance of this complicated operation, place Dr. Hullihen at once 
among the ablest surgeons of the day." It is the more worthy 
of notice here, as having been performed by a dentist who thus 
furnishes a model of what we would have a dentist to be — not 
a mere mechanic, employed to repair the teeth, or, if necessary, 
extract them — but an accomplished physician and surgeon, 
who, while devoting his attention particularly to the teeth, is 
prepared to undertake the treatment of the adjacent parts, how- 
ever formidable and complicated their diseases may be. 

"Miss Mary S , aged 20, daughter of the Hon. William 

S , of Ohio, came to Wheeling, in the spring of 1848, to 



276 TUMORS REQUIRING AMPUTATION. 

obtain relief from the effects of a very severe burn, which she 
had received fifteen years before. The burn was principally 
confined to the neck and lower part of the face, and its cicatrix 
produced a deformity of the most dreadful character. Her head 
was drawn downwards and forwards, the chin was confined 
within an inch of the sternum, the under lip was so pulled 
down that the mucous membrane of the left side came far be- 
low the chin, the under jaw was bowed slightly downward, 
and elongated particularly its upper portion, which made it pro- 
ject about one inch and three-eighths beyond the upper jaw. 
In front there was scarcely any appearance of either chin or 
neck. She was unable to turn her head to either side, the 
cheeks and upper lip were dragged considerably downward ; 
she could not close her eye-lids ; she could not close her jaws 
but for an instant, and then only by bowing her head forward. 
She could not retain her saliva for a single instant ; and, as 
might be expected, her articulation was very indistinct. 

"She had been taken to the city of New York some years 
before, for the purpose of being relieved from this deformity, 
and was placed under the care of two of the most distinguished 
surgeons in that city, who performed an operation by dissect- 
ing up the cicatrix on the neck, then raising the head and 
sliding up the cicatrix from its original position, leaving a raw 
surface below to heal up by granulation. I need scarcely add 
that the operation was entirely unsuccessful. 

"After a careful observation of the case, it became evident 
that such a complicated deformity could be best remedied by 
performing three separate operations : one upon the jaw, another 
upon the neck, and a third upon the under lip. 

"To remove the projection of the under jaw, seemed to re- 
quire the first attention. Unless that could be done the other 
operations, however successful, would add but little, if any, to 
the personal appearance of the patient. This lengthening of 
the jaw had taken place entirely between the cuspidatus and 
first bicuspid tooth of the right side, and between the first and 
second bicuspids of the left. By the elongation, the teeth just 
described were separated on both sides about three-fourths of 
an inch. 



TUMORS REQUIRING AMPUTATION. 277 

"To saw out the upper edge of these elongated portions of 
the jaw, and then to divide that part of the jaw in front of the 
spaces thus made, by sawing it through in a horizontal manner, 
so as to permit the upper and detached portion to be set back 
in its original position — appeared to be the only possible way 
of remedying the deformity. This plan I therefore adopted, and 
performed the operation on the 12th day of June, in the manner 
now to be described : 

"The operation was commenced by sawing out, in a V shape, 
the elongated portions, together with the first bicuspid on the 
left side, each section extending about three-fourths of the way 
through the jaw. I then introduced a bistoury at the lower 
point of the space from which the section was removed on the 
right side, and pushed it through the soft parts close to and in 
front of the jaw, until it came out at the lower point of the 
space on the left side. The bistoury was then withdrawn, and 
a slender saw introduced in the same place, and the upper 
three-fourths of the jaw, containing the six front teeth, was 
sawed off' on a horizontal line ending at the bottom of the spaces 
before named, the detached portion being still connected, on 
the outer and inner sides, to the jaw below, by the soft parts. 

"After having with the bone nippers removed from the de- 
tached portion the corners which were created by the horizontal 
and perpendicular cuts of the saw, it was set back so that the 
edges from which the V shaped sections were removed came 
together. 

"Thus it will be perceived that this portion of jaw and teeth, 
which before projected and inclined outward, now stood back 
and inclined inward, and in its proper and original place. 

"In this position the jaw was secured, by passing ligatures 
around the cuspidati in the detached portion and the now ad- 
joining bicuspids m the sound portion, then taking an impres- 
sion of the jaw in very soft wax, a cast was procured, and a 
silver plate struck up and iitted over the teeth and gum, in such 
a manner as to maintain the parts in that same relation, beyond 
the possibility of movement. 

"The patient declared that the operation gave her little or 
27 



278 TUMORS REQUIRING AMPUTATION. 

no pain. There was a little swelling about the chin during the 
first three days after the operation, but not the slightest uneasi- 
ness. In this way the case progressed ; the gum healed in a 
few days, the jaw united strongly and in the time bones usually 
unite, and the wearing of the plate was discontinued within six 
weeks after the operation was performed. 

"The deformity of the jaw being now removed, the next 
thing to be done was to relieve the confined condition of the 
head, and the distortion of the face and neck resulting there- 
from. This I determined to accomplish, if possible, after the 
manner of Prof. Mutter in similar cases, and I accordingly 
performed the operation on the 31st day of July, assisted by 
Dr. Wissell. 

"I began by dividing the skin immediately in front of the 
neck, about half an inch above the sternum, and then carried 
the incision back about three inches on each side. I then com- 
menced a careful division of the strictures which were so thick- 
ened in front as to extend to the trachea, and on the sides as 
not only to involve the platysma myoides, but a portion of the 
sterno-cleido-mastoid muscle also. After dividing every thing 
that interfered with the raising of the head and the closing of 
the mouth, as far as the incision was now made, it became 
evident that to give free motion to the head, the incision on the 
neck must be extended back through the remaining cicatrix, 
which was at least two inches wide on one side, and about an 
inch and a half on the other. 

"This was accordingly done, the whole presenting a wound 
upwards of nine inches in length and nearly five in width. A 
thin piece of leather was now cut in shape of the wound, but 
somewhat larger, and placing it upon the shoulder and arm, 
immediately over the deltoid muscle, a flap nearly ten inches 
in length and five in breadth, having an attachment or neck 
two inches wide, was marked out, and then dissected up as 
thick as the parts below would permit. This flap was now 
brought around and secured in the wound on the neck by the 
twisted suture, the sutures being placed about an inch and a 
half apart. Between each of these sutures, one, two, and some- 



TUMORS REQUIRING AMPUTATION. 279 

times three small stitches were inserted, depending entirely 
upon the number necessary to bring the edges neatly together. 
These stitches were of fine thread, had a very superficial hold, 
produced little or no irritation, and served to keep the parts in 
better apposition than any other means I could have devised. 
The wound of the shoulder was next drawn together about one- 
half of its entire extent ; the remainder was covered with lint. 
One long narrow strip of adhesive plaster applied around the 
neck to support the flap, and over this a cravat tied in the usual 
way, constituted all the dressing deemed advisable at this time. 

"The patient bore this tedious and very painful operation 
with great fortitude, and uttered scarcely a murmur. She was 
somewhat exhausted, but not from the loss of blood. There was 
no vessel divided of sufficient importance to require a ligature. 

"Aug. 1. During the fore part of last night, the patient was 
somewhat distressed, was very unmanageable, would talk in- 
cessantly, and occasionally sat up in bed. An anodyne was 
administered at 12 o'clock, after which she rested much better 
and slept some. Complains of sickness of the stomach this 
morning; has vomited three or four times ; flap very pale ; pulse 
rather weak. Directed to refrain from all kinds of drinks. 

"2d. Complains only of pain in the shoulder; was much 
distressed the latter part of last night, on account of a retention 
of urine. The catheter was employed, and about three pints 
of urine drawn off, after which she rested well. Pulse some- 
what excited; flap better color. 

"3d. The patient rested well last night; the use of the 
catheter still necessary. All efforts to keep the patient from 
talking and moving unavailing; color of the flap rather pale, 
save at the extreme point and about two inches along the lower 
edge, which is assuming rather a dark blue color. Pulse about 
the same as yesterday ; removed a pin from near the point of 
the Hap, and enveloped the neck in cotton batting. Patient 
complains of hunger; chicken brolh ordered. 

"4th. Patient rested well; the use of the catheter yet neces- 
sary ; complains of slight headache; the color of llie flap nearly 
natural, and even the point is assuming a healthy hue, and ap- 
pears to be uniting; pulse almost natural. 



280 TUMORS REQUIRING AMPUTATION> 

"5th. Urinates without difficulty; bowels moved by injec- 
tions ; patient entirely free from pain ; pulse natural. 

"6th. Dressing removed ; the flap is uniting by the first 
intention along both sides, throughout its entire extent ; the 
greater part of the pins and stitches removed. 

"7th. The remainder of the pins and stitches removed; pa- 
tient perfectly comfortable and cheerful. 

"10th. Sat up all day by the window. 

"16th. Walked out to take an airing. 

"During the whole progress of the cure, there was not the 
slightest swelling or undue inflammation in the flap or about the 
neck. The patient was slightly hysterical for the first few days, 
but never complained of any thing but pain in the shoulder, a 
slight headache of a few hours duration, and the uneasiness oc- 
casioned by the retention of urine. The wound on the shoul- 
der granulated rapidly and skinned over in about six weeks after 
the operation. It was curious to observe ^hat upor touching 
the flap after it had healed in the neck, the patient would always 
refer the sensation to the shoulder or arm from which the flap 
was taken. 

"The confinement of the head, and the distortion of the face 
occasioned by the strictures being now removed, the next step 
was to relieve, as far as possible, the very. great deformity of 
the under lip. 

"The under lip, from being dragged down and greatly 
stretched by the former projection of the under jaw, was ren- 
dered greatly too large, so that it pouted out an inch or more 
further than the upper lip. This, together with a turning out 
of the mucous membrane on the left side, which extended 
nearly down to the lower edge of the chin, making the lip too 
short on that side, was the nature of the deformity yet to be 
relieved. 

"To remove this unseemly appearance of the lip, the inverted 
portion was cut out in a V shape, extending down to the flap 
in the neck, and sufficiently large to reduce the lip to its 
proper size. The edges were then brought together, and secured 
after the manner of a single hare-lip. The wound healed in 



TUMORS REQUIRING AMPUTATION. 281 

the most beautiful manner, and the appearance of the lip was 
greatly improved; but there yet remained a deep depression or 
notch in the edge, sufficiently large to keep exposed the tops of 
two or three teeth, besides preventing the coming together of 
the lips on that side. 

"I now determined to raise, if possible, this depressed por- 
tion of the lip, and for this purpose I passed a bistoury through 
the lip, about two lines from the free edge, first on one side of 
the depression, and then on the other, and then carried the inci- 
sions downward to meet at a point on the lower edge of the chin. 

"The depressed portion of lip now lying between the two 
incisions was next dissected loose from the jaw, and then 
raised to a level with the remainder of the lip, and there re- 
tained by pins, after the manner of dressing a double hare-lip, 
the line of union forming a letter V. 

"This operation was as successful as the others, and the 
original deformity being now removed, the young lady., though 
still bearing evidences of the burn, has the free use of her head, 
eye-lids, jaws and lips, and may mingle in society without par- 
ticular note or remark." 



CHAPTER XX. 

DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

The cavity which bears these names is liable to be the seat 
of a variety of diseases. For the most part these are simple, 
and not at all malignant in their character ; occasionally, how- 
ever, tumors and ulcers of a carcinomatous kind fix their seat 
in this secluded cavity, where their presence is unobserved until 
their local devastations or constitutional impressions have reach- 
ed a most serious extent. 

The danger of diseases of the antrum, however, cannot be 
estimated entirely by their specific character. The geographi- 
cal situation of the cavity gives greater importance to its dis- 
eases than essentially belongs to them. Many a benign tumor, 
originating here, has proved fatal by mere growth and bulk ; 
the danger having been masked by the concealed position and 
the little sensibility of the parts, until interference was useless. 

Nothing can be more important, therefore, than early atten- 
tion to any of the, commonly obscure, symptoms which inti- 
mate the presence of diseased action of any kind in this patho- 
logically important sinus. The dentist commonly has the first 
opportunity to observe these signs and detect their cause, and 
he should always be ready to perceive and interpret them. 

The lining membrane of the antrum is liable to be affected 
by all the diseases common to the mucous tissues. It may be 
congested, inflamed and ulcerated ; it may undergo alterations 
affecting its secretions; it may be the seat of various tumors, or 
may be involved in sueh morbid formations commencing in the 
bony structures or the thin fibrous tissue which attaches it to 
the bones. 

In treating further of diseases of this cavity, I will ask the 



284 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

attention of thareader to, 1st. Dropsy or retention of mucus ; 
2d. Inflammation of the lining membrane ; 3d. Suppuration ; 
4th. Caries, necrosis and other morbid conditions of the bony 
walls ; 5th. Polypi and other tumors ; 6th. The presence of 
insects in the cavity. 

Dropsy, or Retention of Mucus. 

The term dropsy is entirely misapplied to this affection, and 
should be discarded. The disease has no similarity to dropsi- 
cal swellings : those are occasioned by effusion of water, while 
the affection we are considering is a distension of the antral 
cavity by retained mucus. 

If from any cause the antral openings become closed, the 
secretion of the lining membrane, no longer finding exit by 
evaporation, must accumulate in the cavity of the sinus. Being 
retained, it will necessarily degenerate ; being degenerated, it 
will irritate the membrane, and the membrane being irritated, 
will pour^out more than its usual quantity of secretion. The 
quantity accumulated will at length completely fill the cavity, 
and when once the sinus is completely filled, every additional 
drop of fluid thrown into it will cause the whole mass to act 
with great power upon the walls which confine it. However 
thick the walls, and however strongly knit together, they cannot 
withstand the hydraulic pressure continually augmenting within 
them. They are gradually forced outwards, and a rounded 
solid tumor gives external evidence of the outward pressure of 
the contained fluid. 

Until the pressure becomes sufficient to distend the bones, 
the patient does not complain of pain ; but as the walls of the 
cavity gradually yield and press upon the soft parts, pain is felt, 
which becomes more and more severe as the tumor increases. 
The^integuments covering the distended antrum become swollen 
and red. A smooth hard tumor presents itself, either in the 
roof of the mouth, or under the orbit, or under the cheek, and 
unless the contained fluid be speedily evacuated, the contents 
of the antrum will force their way through the bones. 



DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 285 

As the distension of the walls of the sinus indicates nothing 
more than the fact of its being filled with some distending body, 
it may often be difficult at first to decide whether the contents 
be mucus or some kind of solid growth. So long as the tumor 
presents a tolerably uniform hard surface, there can be no cer- 
tainty of the nature of the distending cause ; but the uniformity 
of the tumor, the sense of weight, the slight discomfort or pain 
attending it, and, finally, the discovery of fluctuation will deter- 
mine the diagnosis. 

The indication, of course, is to make an artificial opening 
and permit the escape of the contained matter, and then to make 
such applications to the lining membrane of the antrum, as will 
restore the natural secretion of the part- 
There is no difficulty in making the required opening. The 
antrum is accessible at many points, and might be perforated 
almost any where without danger. Yet it is a very important 
thing to choose that point where the wall is thinnest, and where 
the perforation may be made with least pain and least in- 
jury to the parts, and which affords the most facility for the es- 
cape of the matter, during such length of time as an artificial 
opening may be necessary. 

Jourdain, a French surgeon, who wrote very ably upon dis- 
eases of the sinus, recommended to the Academy of Surgery in 
Paris, that a sound should be passed into the antrum, through 
the natural opening. He represented that the operation was 
feasible, and being so, was, for many reasons, preferable to any 
other. Upon experiment, however, this mode of procedure has 
been found very difficult of execution in all cases, and altogether 
impossible in many, and it is no longer attempted. 

The fangs of the molar teeth sometimes penetrate the cavity of 
the antrum, and generally their extremities are separated from it 
by a very thin bony partition. The cavity of the antrum is de- 
pressed posteriorly, and the position of the molar teeth repre- 
sents the most depending part of it. It is, therefore, most ad- 
visable to make the opening through the alveolus of one of these 
teeth. Should one have been previously extracted, we should 
make the opening through its vacant alveolus; should all these 
28 



286 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

teeth be yet in the jaw, one must be extracted, and of course, 
we should sacrifice a carious, in preference to a sound tooth. 
Should all be sound, it would be best to extract the second mo- 
lar. Sometimes it will be necessary to extract two teeth, in 
order to obtain sufficient room for such an opening as will be 
desirable. 

Sometimes the extraction of the tooth will be followed at 
once by the discharge of the fluid ; an opening having been 
made into the antrum by tearing away the fang. More gen- 
erally, however, it will be necessary to puncture the floor of 
the cavity. 

The instrument preferred by Dr. C. A. Harris, for whose 
opinion, in such matters, I have great respect, is a straight tro- 
car. The point of this instrument having been passed into the 
alveolus, should be pressed against the bottom, in a direction 
towards the centre of the antrum. The intervening plate of 
bone, may then be easily pierced by a few rotary movements of 
the trocar. Care must be taken so to moderate the pressure 
applied, that the instrument may not, upon the giving way of 
the floor, be suddenly pushed across the cavity and made to 
wound the opposite surface. 

Upon the removal of the instrument, a gush of fluid will fol- 
low. Should the opening not be sufficiently large to permit of 
the free passage of the thick matter which may be contained in 
the cavity, it will be easy to enlarge it. 

Some surgeons advise that a bougie should be kept in the 
opening, others prefer a canula of lead or silver. Richter ob- 
serves, that if a canula be left in, it should be carefully stopped, 
lest particles of food and drink should find their way into the 
cavity. Deschamps and Harris advise that the canula be se- 
cured to the adjacent teeth, and left in the opening. If a bou- 
gie be used, it should be removed two or three times a day, in 
order to permit the matter to escape. 

If fistulas have previously been formed, they will generally 
close after the dependent opening has been made. Should they 
not heal readily, their closure may be facilitated by touching 
their callous edges with nitrate of silver. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 287 

Having removed the mechanical evil, by evacuating the ac- 
cumulated fluids, we must accomplish a cure by such constitu- 
tional treatment as the case may require, and by suitable local 
applications to the lining membrane of the antrum. 

At first, warm water may be injected, in order thoroughly to 
cleanse the surface of the membrane, and subsequently we may 
throw in astringent or mildly stimulating applications, such as 
port wine and water, solutions of sul. zinc, sul. capri, or even 
of nit. argenti. As the secretions are fetid, a weak solution of 
chloride of lime, or chloride of soda, may, be injected two or 
three times a day. Should the gums be inflamed, leeches must 
be applied from time to time, until the inflammation be sub- 
dued. 

As the morbid condition of the mucous lining of the cavity 
may result from the irritation of diseased teeth or fangs, all sus- 
pected irritants of this kind must be removed. 

In Mott's edition of Velpeau, I find the following remark — 
"If, as happens frequently, the sinus is distended by any liquid, 
its anterior wall swollen out in the form of a border under the 
cheek is, in general, so soft that a bistoury or scalpel penetrates 
it without any difficulty. The operation is then extremely sim- 
ple. Having freely incised the superior part of this border 
transversely between the cheek and malar bone, I excite its 
inferior portion with a second cut of the bistoury. The loss of 
substance thus made, remains fistulous, and prevents the sinus 
from filling up a second time. The three patients which I 
treated in this way were promptly cured." 

Should the teeth have been long previously lost, and the al- 
veolus obliterated, the operator must choose between dissecting 
off the gum and boring his way into the antrum at the point 
already indicated, or performing some one of the several other 
modes of operation which have been preferred. Lamorier di- 
rects, in such cases, that we should penetrate into the maxil- 
lary sinus immediately below the zygomatic process, between 
the cheek bone and third molar tooth. This is the point which 
corresponds to the summit of the cavity, where the walls are 
thinnest. An assistant, provided with a blunt hook draws the 



288 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

labial angle outwards and upwards. The operator incises the 
fibro-mucous membrane, which covers the bone at the point des- 
ignated, by means of a scalpel or good bistoury; then perforates 
the osseous wall with a solid pointed instrument, enlarges the 
opening as much as he judges necessary, and finishes by in- 
troducing into it a tent of lint. 

Other surgeons prefer the method originally suggested by 
Molinetti, first to divide the cheek between the projection of 
the malar bone and the suborbital foramen, then to penetrate 
through this wound into the interior of the sinus. 

In a patient who had no longer any molar teeth, the idea oc- 
curred to Gooch of perforating the antrum highmoranium on its 
nasal wall, and of inserting therein a leaden canula. 

A buccal fistula of the maxillary sinus suggested to RufFel to 
penetrate that cavity with a trocar, and to compel it to come 
out above the gum, in order thereby to establish a counter 
opening. A seton was then introduced and kept in this pas- 
sage during the space of six weeks with such benefit that suc- 
cess crowned the enterprize of the surgeon. 

Cullison recommended that if the fluctuation should become 
perceptible at the vault of the palate, the artificial opening 
should be established there. Basch and Henkel have suc- 
ceeded by means of a meche introduced through a fistula in the 
floor of the orbit, and brought into the mouth through an open- 
ing in the alveoli. Bertrandi proceeded in the same manner, 
with the exception of not using the seton, in a patient who 
could not open his mouth, and who also had a fistula in the 
orbitar wall of the sinus. 

In the process of Weinhold, the surgeon first directs his in- 
strument to the upper and outer part of the canine fossa, directs 
it obliquely downwards and outwards, carefully avoids the 
branches of the suborbitar nerve, perforates the sinus and then 
leaves a roll of lint in the wound. If the sinus has no other 
issue, Weinhold recommends that we should perforate it through 
and through, either by pushing the first instrument through the 
palatine vault into the mouth, or by means of a curved needle 
above the alveoli, when we wish to place the counter opening 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 289 

external to the guru. An eye which both instruments here en- 
ables us at the same time to pass through the sinus the con- 
ducting thread of a meche of lint destined to perform the duty 
of a seton, and which may be smeared with any proper oint- 
ment.* 

The disease we are considering is not by any means serious, 
as it depends upon slight and generally temporary alterations 
in the antral membrane. Recovery, however, is slow, and 
we must not expect to accomplish a cure under a period of 
several weeks. 

Inflammation. 

The lining membrane of the antrum may be inflamed from a 
variety of causes. Severe blows upon the face, injuring, per- 
haps breaking, the external walls of the cavity; cold acting for 
a long time upon the face ; the accumulation of mucus within 
the cavity, undergoing degeneration, and becoming irritating 
to the surface upon which it rests — all these may, occasionally, 
induce inflammation of the sinus. But, undoubtedly, the most 
common cause is found in the diseases of the teeth, gums and 
dental periostea, which are communicated to the lining of the 
antrum. 

The chief symptom of inflammation of the sinus is a dull, 
continuous pain in the upper jaw, gradually becoming more 
severe, spreading to the border of the alveolus, and seeming to 
fix itself in the roots of the molar and canine teeth. It some- 
times occupies the whole side of the face, extending to the or- 
bit and frontal sinus. The inflammation may begin in the 
teeth, and gradually extend to the antrum, in which case the 
severer and more paroxysmal pain of tooth-ache will accompany 
the duller, deeper, more continuous ache of the antrum. As 
the pain increases, fever is developed, which will be more or 
less considerable, according to the degree of the inflammation 
and the sensibility of the patient. 



* Mott's Velpeau's Surgery, vol. iii. 
28* 



290 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

Inflammation of the sinus can hardly be confounded with 
engorgement. In the latter case there is swelling of the bones, 
and in the former there is pain from the commencement of the 
attack. In fact, it cannot be mistaken except for inflammatory 
odontalgia, affecting the roots of the molar teeth; and from 
this, if these teeth be decayed, it cannot always be distin- 
guished. 

In inflammation of the antrum, we must use leeches to the 
gums, and, unless there be some good reason for omitting it, 
general bleeding from the arm, saline cathartics, and, in short, 
the whole antiphlogistic means. Opium may be used freely to 
lull the pain, and warm applications, by vapor or poultices, may 
also be tried. 

If, however, there be pain which seems to be similar to tooth- 
ache, and if some of the teeth, especially the molars, be dis- 
eased, and especially if one or more of them have been in the 
habit of aching, no permanent cure can be expected without 
removing them. 

For the most part, however, we ought not to attempt this 
operation while the inflammation is unsubdued, as the injury 
inflicted by the violence of extraction must increase the vascu- 
lar excitement of the part, and aggravate the distress of the pa- 
tient. When the inflammation has been subdued, and the 
morbid irritability of the parts has subsided, the mouth should 
be carefully examined, and all diseased teeth removed. 

Suppuration. 

The inflammation of the mucous membrane of the antrum 
generally terminates in resolution ; sometimes, however, it ends 
in the formation of pus, or suppuration. 

When such is unfortunately the case, the pain gradually be- 
comes less intolerable, and finally ceases in a great degree. The 
fever subsides, the patient may feel some rigors, and instead of 
acute pain there is felt a throbbing sensation in the part. If 
the outlet of the sinus be open, pus will escape into the nostril, 
and unless it finds a free vent, some pouting will, after a while, 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 291 

be perceived in the alveolar border, or a bony protrusion will 
be noticed upon the cheek. 

Suppuration of the antrum may occur without preceding ac- 
tive inflammation. Some cachectic habits are exceedingly 
prone to a slow, feeble inflammation, which is not attended by 
acute symptoms, and is apt to end in the formation of ill con- 
ditioned pus, and frequently in ulceration of mucous membranes. 
This kind of suppuration is not uncommon in the antrum, and 
the inflammation preceding it is not unfrequently unperceived 
until the greater mischief of suppuration or ulceration has been 
accomplished. Even after suppuration, the true nature of the 
evil may be unsuspected ; the more so, that the preceding in- 
flammation has been unperceived. 

When there is dull, continuous pain along the border of the 
sinus, apparently not depending upon caries of the teeth, if 
there be swelling of the sinus, especially if the patient be of a 
strumous habit of body, we may suspect suppuration of the 
sinus. Should pus escape into the nostril, of course the diag- 
nosis will be complete. 

If there are any carious teeth, they should be removed. They 
may be the cause of the pain ; they may even be the cause of 
the suppuration. In any case, their presence is mischievous, 
and, moreover, we must have access to the cavity through the 
alveoli. 

The treatment must be similar to that recommended for mu- 
cous accumulation. Should the disease be the consequence of 
general ill health or depraved constitution, the proper consti- 
tutional means must be employed. The mouth must be cleared 
of decaying teeth, and the patient must avoid exposure to cold. 

Caries, Necrosis, and other Morbid Conditions of the Bony 
Walls. 

Caries is an affection of the bone, somewhat analogous to 
ulceration of the soft parts. In this disease there is loss of 
substance, causing, for the most part, irregular perforations of 
the osseous structure, giving, in many instances, a honey- 



292 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

combed or worm-eaten appearance; at other times the destruc- 
tion may appear in a continuous superficial excavation. There 
is a discharge of a dark, fetid, sanious pus, and frequently a 
growth of fungous granulations shooting up from the excava- 
tions. 

The bones, though hard and dense, are vital structures. 
They are supplied with blood-vessels and nerves, and cellular 
tissue. They are capable of growth and reproduction, of ab- 
sorption, and separation of dead from the living parts, by a 
vital process. Of course they are subject to disease — and to 
diseases only differing in appearance from those affecting 
softer structures, by the necessary modifications resulting from 
the peculiar density of the osseous structures. 

Caries may occur in bones from the same causes which in- 
duce ulceration in the soft parts. Any thing which lessens the 
vitality of the parts, diminishes its nutrition, or causes exces- 
sive intersticial absorption, may cause caries. 

External injuries may be the exciting cause, though far more 
commonly productive of necrosis. Long continued inflamma- 
tion or irritation of neighboring parts; inflammation of the 
periosteum, and, above all, certain constitutional vitiations, are 
causes of caries. 

Scrofulous persons, and those whose fluids are tainted with 
the syphilitic poison, are most apt to engender this and other 
diseases of the bones. 

Generally, a fistulous ulcer, somewhere in the vicinity of the 
carious bone, will discharge the dark colored, fetid and often 
bloody pus which I have mentioned, and this will generally be 
a sufficient evidence that caries lies beneath. M. Strack, how- 
ever, is quoted by Jourdain, as having met with an ulcer in 
every way similar to those usually marking caries, which was, 
in reality, unconnected with any disease of the bone. 

When the finger can be brought in contact with the bone, 
which, however, can rarely be the case, the roughened .feeling 
of the surface will at once determine the diagnosis. When this 
kind of examination cannot be made, a silver probe may often 
be passed to the bottom of the fistula, and the rough, grated 



DISEASES OF THE ANTRUM OF MAXILLARY SINUS. 293 

surface of the bone perceived. Very often, however, the canal 
through which the pus escapes is too tortuous to permit of 
satisfactory exploration. 

If caries be not checked, it will end in necrosis, or complete 
death of the diseased bone; caries, however, is not necessary 
to necrosis, for the latter may occur without being preceded by 
the former. 

Necrosis may be caused by any means which destroys the 
nutrition of the bone or any part of it. These causes are some- 
times external; more commonly, perhaps, they depend, at least 
for their predisposing cause, upon constitutional vitiations, or 
defects of nutrition consequent upon general pravity. 

When the walls of the antrum or alveoli are carious or ne- 
crosed, the soft parts adjacent inflame, ulcerate, and discharge 
a fetid, sanious or ichorous pus. Sometimes the gums lose 
their vitality, become gangrenous, and are slowly separated by 
sphacelation. 

Dr. Harris observes, that it frequently happens, that while 
caries is preying upon the antrum, its walls become softened 
to such an extent that they may be bent. This alteration of the 
bone, as well as the caries and necrosis, are, he says, in almost 
every instance, preceded by some other affection of the antrum. 
Caries and gangrene of the antrum are very distressing affec- 
tions, as, even when there is vitality enough in the bone to 
check the caries or throw off the sequestrum, the process is very 
slow; the fetid discharge of pus and the extreme sensitiveness 
of the inflamed and fungous soft parts, produce great misery to 
the sufferer, and excite the lively sympathy of all who witness 
his distress. The severest operation, which promises relief, 
will commonly be endured with patience by the unhappy victim 
of so protracted and intolerable a disorder. 

It is not always easy to detect the existence of caries in the 
antrum, as the symptoms manifested by the surrounding parts, 
or detected through them, are similar in different affections. 
Should sanious pus make its appearance, we may generally 
infer the existence of caries; but in a few instances, the pus 
has been of a normal character and appearance, and though 



294 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

the presence of the pus, in appearance such as commonly 
attends caries, may satisfy us that such a state of the bone ex- 
ists, the absence of such pus is not equally satisfactory evidence 
that the bone is entire. The exfoliation of pieces of bone would 
of course dispel all doubts as to the nature of the disease. 

By probing where there is an ulcer, or by making an artifi- 
cial opening where none exists, we can gently introduce a blunt 
probe and explore the suspected bone. 

When the alveolar border or floor of the antrum is the seat 
of the caries or necrosis, there is little difficulty in ascertaining 
the seat and nature of the disease. 

The swollen and purplish appearance of the gums will attract 
attention to the alveolar border: and soon separating from the 
sockets, ulcerating and sloughing, they will lay bare the dis- 
eased bone, and expose the true character of the disease. 

"When situated in the floor of the antrum, the rough denuded 
bone may be easily felt with a probe or stilet, introduced through 
the fistula in the gums or alveolus of a tooth from which the 
matter is discharged." — (Harris.) 

Whatever may be the remote causes of caries and necrosis 
of the antral bones, the immediate cause is defective nutrition, 
resulting from disease or destruction of the periosteum; and 
among the most common causes of periosteal disease, are the 
irritation produced by diseased teeth, and that caused by the ac- 
tion of fluid detained in the cavity. 

The first step towards cure, must be to evacuate any mucus 
which may be distending the antral chamber, and to remove 
any diseased teeth which may be suspected of causing irrita- 
tion. 

The following case reported by Deschamps* will serve to 
show that I have not laid unnecessary stress upon the agency 
of diseased teeth, in the production of caries of the maxillary 
bones. 

Mr. Martin the elder, who enjoyed at Lyons, a well merited 
reputation, communicated to me the following case: 

*Traite des Maladies des fosses Nazales et de leurs sinus. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 295 

M. D. had a carious tooth in the upper jaw of the left side. 
A dentist having refused to extract it, a violent inflammation 
occurred in the alveolus, and subsequently was communicated, 
to the maxillary sinus. The result was a deposit of matter in 
the cavity of the antrum, and consequently a necrosis of the 
greater part of its anterior and inferior wall. 

When the patient called upon M. Martin, he was passing a 
bloody and very fetid matter through his left nostril. The pos- 
terior part of the alveolar border felt denuded, and was covered 
with fetid mucus. Externally a considerable tumor occupied 
all the left side of the face, from the orbit to the border of the 
lower jaw. The appearances fully satisfying Mr. Martin as to 
the nature of the affection, he decided to attempt the extraction 
of the pieces of necrosed bone, in order to open a way into the 
interior of the sinus, and explore the state of the lining mem- 
brane. 

By the aid of the elevator, he detached a fragment about ten 
lines in length, which appeared to belong partly to the alveolar 
border, partly to the palatine and partly to the malar apophysis. 

In the meantime, carrying his finger into the opening he had 
made, he perceived yet two or three rough points, which led 
him to believe that he had not yet got away all the fragments. 
He postponed further efforts to the next day. Then he took 
away another fragment which appeared to belong to the ante- 
rior wall of the sinus, and which was larger than the piece pre- 
viously removed. After this he could find no more asperities, 
and he assured the patient that the operation, so far as the ex- 
traction of bone was concerned, was completed. No fungus 
could be perceived, and after the first day, the discharge of pus 
through the nostrils and mouth had nearly ceased. 

In less than five days, the tumor of the cheek had subsided : 
the patient suffered no pain, and his breath ceased to be fetid. 
The only remaining inconvenience was an imperfection of 
speech, which resulted from the communication between the 
sinus and the mouth, and which would be remedied when the 
opening of the alveolus should be closed either by the junc- 
tion of the gums or reproduction of osseous matter. 



296 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

Dr. Francis, of New York, describes a form of this disease 
which occurs in infants in hospitals, and under circumstances 
when the nutrition is impeded, as by scrofula, unwholesome air, 
insufficient aliment, &c. The disease frequently begins at the 
edge of the gums in contact with the incisor teeth. The soft 
parts become tumid with hardness and pain. Sometimes the 
greater part of the side of the face assumes an erythematous as- 
pect without any premonitory signs ; and this is subsequent- 
ly marked by spots of a dark purple or brown color. Sometimes 
the part becomes speedily sphacelated, sloughing commences 
and emits fetid exhalations. The tongue is loaded with a 
foul sordes, and the breath becomes exceedingly offensive, when 
coma will supervene and death suddenly ensue. In other 
instances the teeth will become loose in the commencement 
of the disease, and not unfrequently drop out on the slightest ex- 
ertion or motion of the jaw. The necrosis in some cases, will 
involve full one side of the jaw, and the ulceration extend equally 
over the soft parts and affect the alae nasi, the nose itself and the 
cheek nearly to the orbit of the eye. Very soon the sphacelated 
flesh falls in, and the internal structure of the mouth will be 
exposed, while the lips will become tumid, painful and dis- 
colored. These mordid changes, to a greater or less extent, 
are found to involve, very speedily, the teeth, alveoli, mucous 
surfaces and cheeks. The disease is very dangerous, and 
often rapidly fatal. 

In these cases, the disease is evidently the effect of con- 
stitutional causes, and no local treatment can arrest the devas- 
tation. It was once fashionable for surgeons to make use of the 
most violent means for the cure of caries. The diseased bone 
was cut or burnt away, and the subjacent part carefully cau- 
terized with a red hot iron, in order to prevent the spread of 
the disorder. Such terrible means were rarely justifiable. When 
the disease is entirely local, and the constitution sound, all that 
the surgeon can do is to remove the cause of the caries, if yet 
existing — to lay bare the diseased part, in order to give egress 
to the fluids, and admit the atmospheric air, which is a stimu- 
lant to the parts — or any other moderate stimulant which may 



DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 297 

seem likely to hurry the process by which the great surgeon, 
nature, is limiting and repairing the injury. The diseased 
parts should be cleansed with astringent and detergent washes; 
loose pieces of bone should be removed, and the patient ren- 
dered as comfortable as possible, and properly sustained by such 
nutriment as may be best adapted to his state of strength. Med- 
dlesome surgery is bad. 

When there is constitutional disorder, causing caries, or pre- 
venting the curative process, there will be no prospect of relief, 
unless the constitutional disease be removed. If the venereal 
poison has tainted the system, it must be counteracted by the 
specific means which so generally neutralize it. Should scrofula 
be the form of constitutional pravity, we must use, with far less 
hope, those general measures of regimen, diet and medication, 
which promise most in such cases. 

When necrosis has taken place, the bone must be removed. 
By doing this, we do not interfere with, but assist nature, ac- 
complishing at once, by mechanical means, what by the natural 
effort might not have been effected during weeks or months. 

Should a very large opening be made in the floor of the an- 
trum, it may not be closed by the unaided efforts of nature. In 
such case, it has been recommended to cauterize the interior 
circumference of the opening, in order to remove the edges, and 
induce greater activity in the parts. If the opening has been 
too great to permit of closure by the process of reproduction, 
we must make the best substitute we can for the lost parts, as 
it is imperatively necessary to close the cavity. "An obturator 
of gold should be accurately fitted to the parts, and secured by 
means of a broad clasp to a molar or bicuspid tooth; and if 
there be none suitable on the side of the mouth to which it is 
to be applied, the gold should be extended to one on the oppo- 
site side. If it be necessary to replace the teeth lost with arti- 
ficial ones, these may be so mounted that the plate upon which 
they are set shall cover the opening into the maxillary sinus, 
and thus obviate the necessity of any other obturator." — Harris. 



•29 



298 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 



Softening of the Bony Walls. 

Mollities ossium, or softening and increased flexibility of the 
bones, is due to a diminution of the normal quantity of the 
phosphate of lime, to which earthy ingredient the hardness of 
the bones is due. This may occur either from absorption of the 
earthy matter, or failure of the arteries to deposit it in sufficient 
quantity. It is a rare disease, but it sometimes occurs in the 
antrum. Unless accompanied by a similar condition in other 
osseous structures, it may be regarded as the consequence of 
some pressure from within the cavity, either by a tumor or con- 
tained fluid. So far as the softening itself is concerned, it 
cannot be considered a subject for medical or surgical treatment. 

Exostosis. 

This affection is a hypertrophy or morbid growth of the 
bone, in which the phosphate of lime is deposited in unusual 
quantity, and a hard tumor occasioned. It is not painful of 
itself, but by distension of the periosteum and superincumbent 
soft parts, it may gradually become a source of great distress. 
Generally, however, as the tumor augments slowly, the soft 
parts adjust themselves to the increased bulk of the bone, and 
the patient escapes serious suffering. Much, however, will 
depend upon the magnitude and position of the swelling, and 
upon the attendant condition of the periosteum. Should this 
be inflamed and sensitive, it may occasion acute pain. 

I have already described this kind of morbid growth, in 
treating of tumors. 

The bones of the face have very often been the seat of exos- 
tosis, and many formidable operations have been performed for 
the removal of such tumors. A number of such cases and ope- 
rations have been described, both by the older and modern sur- 
geons.* 

These tumors sometimes attain to great size. M. Beaupreau 

*|See Mott's Velpeau, vol. iii, p. 134. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 299 

presented to the French Academy, in the year 1767, an ana- 
tomical preparation, consisting of a tumor which occupied the 
whole right maxillary sinus, and several of the neighboring 
bones. Its largest circumference is about twelve inches. The 
upper part of the maxillary bone projects on the side of the 
orbit, and straightens the cavity ; the os unguis is included in 
the mass of the tumor, and is nearly effaced. The nasal bones 
of the left side are displaced, and the right nostril entirely 
closed up; and the exostosis projects so much on the left side 
as to be nearly under the malar bone. "Exteriorly," says Bor- 
denave, "the tumor had a smooth and polished appearance, and 
its upper part was very hard. Interiorly, the substance of the 
bone was spongy, and not unlike pumice-stone." 

Sir Astley Cooper describes a case of exostosis of each an- 
trum, which pushed out both eyes, and eventually destroyed 
the patient by pressure upon the brain. 

Jourdain notices an interesting case of this kind, reported by 
M. David, chief surgeon of the Hotel-Dieu of Rouen, and adds 
the following, which came under his own observation : 

Joseph Forcade, surgeon, had a son, who in early life gave 
promise of great vigor of mind and body. When six years old, 
he had the small-pox, which ran a most favorable course. 
When twelve years old, his father lanced a tumor at the inner 
canthus of the right eye, which suppurated for a long time after. 
Immediately after this, a prominence appeared about the mid- 
dle of the nasal process of the right superior maxilla; and in 
spite of every application, steadily increased until it had attain- 
ed considerable size. When the boy was fifteen, both maxillae 
were equally enlarged ; the bones of the nose seemed buried 
between the tumors, and its cartilages were so compressed as 
to impede breathing. The deformity was great, and at the 
age of twenty became, by the growth of the tumors, monstrous. 
The lower jaw became also exostosed, and acquired a very 
great size. 

Though the deformity was shocking, it did not prevent the 
lad from travelling about and gratifying his naturally curious 
disposition. He was clever, lively, fond of good living, and 



300 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

particularly of stimulating drinks. At the age of forty-four he 
was seized with a malignant fever — his first sickness since 
infancy — from which he was slowly recovering, when he was 
seized with pneumonia, of which he died. 

Upon post-mortem examination, says Jourdain, I could 
find on the face no trace of any muscles except those of masti- 
cation ; but the skin seemed tightly drawn over the periosteum 
covering the numerous tumors. The head and face were every 
where exostosed, and as hard as marble. When the brain and 
soft parts were removed, the bones weighed in all more than 
eight pounds. The lower jaw alone weighed one pound, three 
ounces. The usual weight of this bone in an adult is one pound, 
nine ounces, showing an increased weight, in consequence of 
these exostoses, of six pounds, seven ounces. The patient 
had never complained of pain, either in his head or face. 

The symptoms of maxillary exostoses are very obscure. We 
have already seen that the disease may exist to an enormous 
extent without causing pain, the soft parts gradually thinning 
and distending before the pressure. When pain does exist, 
that symptom alone is not sufficient to convince us of the pres- 
ence of exostosis. We have no certain sign but the peculiarly 
hard bony swelling. 

When the disease is accompanied by periostitis, which it is 
particularly liable to be when occasioned by syphilitic constitu- 
tional vitiation, the pain may be sufficiently acute. 

It is in cases such as these, that constitutional treatment has 
been found to arrest the deposition of bony matter, and the 
remedies most successfully used have been precisely such as 
are most efficient in constitutional lues. When no such taint 
exists, little can be done except to remove the tumor before its 
extent renders an operation difficult or impracticable. In many 
instances this has resulted in permanent relief. 

Fistula of the Superior Maxillary Bone. 

Bones seem, notwithstanding their density, to be capable of 
inflammation, and even of abscess. I have already mentioned 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 301 

caries as a kind of osteose ulceration, and there are many cases 
on record which seem to show that pus may be formed within 
a bone, distend its layers and ultimately perforate its structures 
and evacuate itself through a fistulous opening. Probably in 
such cases, the suppuration is in the cellular tissue of the or 
gan, rather than in the proper osseous tissues. 

Jourdain records ten cases of this character, of which I have 
selected the following : 

Case I. — A lady suffered with inflammation of the root of 
an upper first bicuspis on the right side, followed by alveolar 
abscess. After the inflammation had subsided, the tooth was 
removed ; but a fistulous opening still remained, emitting an 
ichorous discharge. After three months endurance of this, the 
patient took advice, had the fistula cut out and dressed with 
balsam. It healed, and for five months seemed perfectly cured. 
But the bone again swelled on the site of the old disease, and 
now extended as far as the second molar, was very hard, and 
was attended with deep seated pains : the. gums were inflamed 
and the tumor increased daily. 

Consultation was held, and opinions differed. Some thought 
it exostosis, others that the sinus was involved. The late M. 
Morand called me (Jourdain) into the case, and we concluded, 
upon careful examination, that by piercing a swollen spot in the 
gum just above the old fistula, we should come upon an open- 
ing into the interior of the bone. The introduction of an in- 
strument to the depth of a line and a half caused a free discharge 
of sanguino-purulent matter, and the probe passed very freely 
into the cavity in the bone, the walls of which, above and below, 
seemed very firm. The socket of the extracted tooth had com- 
pletely healed up. 

M. Morand was in favor of an incision through the bone for 
the purpose of excising the distended portion of bone, but 
with that unprejudiced liberality which always marks the man 
of true wisdom, he yielded to my arguments in favor of the cav- 
ity. I introduced the hot iron into the fistulous opening three 
times in eight days, following it up with suitable injections, 
which frequently brought away small fragments of bone from 
29* 



302 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

the interior of the cavity. The alveolus was soon reduced to 
its natural size, and in forty-three days the patient was perfect 
ly cured. 

Case II. — Madame Massonet was referred to me by M. Mo- 
reau, of the Hotel Dieu, for a fistula above and between the 
first and second superior incisors. At the posterior part of the 
palatine arch there was a considerable tumor, without pain, 
softening, or change of color. From the summit of this tumor 
along the inner side of the alveolar ridge was a prominent line 
which seemed to mark the course of a fistulous canal from the 
external orifice to the tumor behind. 

No further cause could be assigned than the fact that some 
years previously, the patient had received a severe fall, from 
which time the second molar became painful and gradually 
loosened. I removed this tooth, but without any benefit to the 
tumor. The other teeth were sound. Injections and other 
means had been tried at the time of the appearance of the ex- 
ternal fistula, but unsuccessfully. I regarded this case as one 
of true abscess of the bone. I ventured, M. Morand approving, 
to enlarge the external opening and make an incision through 
the entire palatine tumor, which discharged only blood. Suit- 
able injections and gargles were used, but to no purpose. I 
then decided to lay open with a knife the whole course of the 
supposed canal above mentioned, and touch it with mercurial 
water. On the third day, exfoliation of the parts thus touched 
exposed this canal. The subsequent treatment was very sim- 
ple. The fistula was readily closed ; and in six weeks the pa- 
tient was sent home, perfectly restored. 

Case III. — Madam Boillard had a fistula on the anterior 
surface of the superior maxillary bone, the result of an alveolar 
abscess of one of the incisors. Those teeth were so much 
worn away as scarcely to project above the gum, but were not 
at all carious. An operator, who was consulted, extracted the 
second right incisor, which was immediately under the site of 
the abscess, and subsequently the first incisor of the same side, 
but without benefit. He then gave up the case, and the lady 
consulted me. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 303 

I discovered by the introduction of the sound that the fistu- 
lous canal extended from the right second incisor in a tortuous 
direction, to the left canine, and as the two incisors on this 
side were very loose, I extracted them and found their sockets 
much softened. By destroying this softened bone, I established 
a free and direct communication for the escape of the purulent 
secretion of the fistulous canal. By medicated pledges of lint, 
I healed the parts. There was some exfoliation of the alveolar 
substance, and a cure speedily resulted. 

We see from this case, that caries is not the only cause of 
this disease. Irritation and inflammation of the dental pulp 
may occasion suppuration within the tooth cavity, which find- 
ing no vent in the direction of the crown, must escape at the 
extremity of the root, and may cause abscess, infiltration of the 
alveolar structure, and other grave injuries. In such cases a 
canal might be drilled through the crown, thus giving a direct 
escape for the matter, but if the suppuration have already ex- 
tended to the alveolar socket, the extraction of the tooth is most 
advisable. (Extraction is always most advisable.) 

Case IV. M. Petit sent to me a boy, who for a year past 
had been troubled with a fistula just above the left nostril. It 
had come without any previous dental inflammation or tooth- 
ache, and had, therefore, been supposed by those who saw the 
case before me, to be consequent upon caries of the alveolus. 
A long and painful treatment based upon this diagnosis, served 
only to increase the ulcer. With my probe I could touch the 
root of the second incisor, which, however, had never given 
any pain or uneasiness. On pressing my probe up with some 
force, I gave vent to a considerable discharge of pus, yet there 
was no tumefaction of the gum or loosening of the tooth. 
With some difficulty I prevailed upon the patient to allow the 
extraction of the tooth. This done, the pretended cancer healed 
in eight days. 

In this case there was evidently inflammation of the alveolar 
or exo-dental periosteum. 

Case V. A person came to Paris for the relief of an affection 
which resulted from alveolar abscess over the fangs of a decay- 



304 DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 

ed first molar of the right side. After the first attack, although 
the abscess discharged itself freely, a sensation remained in the 
cheek, as though there was a small stone there. The second 
attack though attended by a free escape of pus, left the cheek 
hard and swollen, and the eye-lid much distended with a pecu- 
liar clammy feeling in the region of the zygomatic and malar 
bones. I first saw the disease at this stage. 

On examining the mouth, I found a fistula between the gum 
and cheek, which penetrated the latter in a tortuous direction, 
and discharged an ichorous fluid. I removed the fangs of the 
first molar, but only blood followed the extraction. 

On the fourth day, fluctuation was perceptible under the eye- 
lid, and on the sixth day, I made an incision then in the direc- 
tion of the fibres of the orbicularis muscle. As the swelling 
subsided, I used a compress bandage, taking care to keep open 
the incision till all deep seated suppuration had ceased. The 
subsequent cure was attended with no difficulty. 

The student will find a number of other cases reported by 
Jourdain, whose work on the diseases and surgical operations 
of the mouth is a treasury of information upon these subjects. 
Though an old work, it is little known to the profession in 
this country, as it was not translated until the present year. 
An excellent translation, enriched with a number of very just ob- 
servations, has recently been published by Messrs. Lindsay & 
Blakiston of Philadelphia. This translation is the work of a 
graduate of the Baltimore College of Dental Surgery ; a young 
gentleman of much promise, whose extreme modesty has not 
permitted him to announce his name. The work should be in 
the hands of every surgeon, and surgeon dentist in the land. 

Ozena* 

This is a term applied to all these cases of fetid breath occa- 
sioned by inveterate ulcers of the primary air passages. These 
ulcers are sometimes seated in the antrum, sometimes in the 

* 0£i7, a stench. 



DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 305 

nasal fossa and are frequently connected with and owe their 
fetor to caries of the bones. They are, therefore, more com- 
mon in syphilitic and scrofulous subjects. 

The breath of persons afflicted with ozena is often so offen- 
sive as to render them almost intolerable to others, and the 
consciousness of the disgust which their presence occasions, is 
naturally a source of continual mortification and distress. 

Where the ulcer can be perceived and reached, it should be 
touched with the nitrate of silver, and the application repeated 
until cure is effected. When no direct application can be 
made through the natural openings, as must be the case 
when the sore is seated in the antrum, an opening must be 
made as before directed, and a solution of nitrate of silver in- 
jected, if the caustic cannot be immediately applied to the 
part. 

If the patient be tainted with syphilitic disease, no local remedy 
can be effectual. He must be placed at once under proper con- 
stitutional treatment, and this must be persevered in until the 
vice be eradicated. In case of scrofula, the same remark ap- 
plies. Local remedies, however, are not by any means to be 
neglected. They may very much hasten the cure, and perhaps 
may render effectual, constitutional means which otherwise 
might be impotent. 

Every expedient should be tried before leaving the patient to 
suffer the distress and serious inconveniences attendant upon 
such a disgusting disease. 

Polypi and other Tumors. 

Polypi* are tumors of various consistencies and rapid growth, 
which appear in several cavities of the body which are lined 
by mucous membranes, but are most common in the nose, uterus 
and maxillary sinus. They also occur, occasionally, in the rec- 
tum and vagina. They occur much more frequently in the nose 
than elsewhere, and next to the nose, in the uterus. 

* IIoXv;, many — «ouj, a foot. 



306 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

The tumor growing into all the irregular cavities of the nasal 
fossa, &c. has sometimes an irregular form, which from a fancied 
resemblance to the animal of the same name, has originated its 
designation. 

Several varieties of polypoid tumors are described by writers. 
Mr. Pott thought one class of them always malignant, and an- 
other benign. The one like carcinoma being painful, causing 
constitutional irritation through morbid processes developed 
within itself, and tending to convert adjacent tissues into its own 
morbid structure, the other not painful, not causing any suffering, 
local or constitutional, except indirectly by producing pressure 
upon other parts or rilling up cavities which are necessary to be 
kept open. In short, he considered that one class of polypi, 
the benign, are inconvenient or even fatal, merely by mechani- 
cal action ; while the other, or malignant class, though equally 
troublesome by their pressure and obstruction which they cause, 
are per se pathologically dangerous to the health and life. 

Deschamps describes four varieties, which he calls vascular 
fungus, mucous lymphatic, scirrhous and sarcomatous. 

Dr. Warren classifies polypi as membranous, fibrous and vas- 
cular. The latter, he says, is rare. Jourdain recognised three 
kinds — one loose, pale, indolent and benign, also called vesic- 
ular polypus ; another, hard, unyielding, livid and painful, 
marked with veins, and often hideous ; and a third, fleshy, 
elongated and easily stretched. 

Samuel Cooper observes, "Some polypi are red, soft and 
sensible, but free from pain, and exactly like a piece of healthy 
flesh. When this kind of polypus is of a softer consistence, 
semi-transparent, and of a pale, yellowish color in consequence 
of being less vascular, it is called the gelatinous polypus, and 
usually arises from the mucous membrane of the side of the an- 
trum, or the middle of the cavity of the nostril between the up- 
per and lower turbinated bone. No doubt carcinomatous tu- 
mors in the antrum have occasionally been confounded with 
polypi, but there is no good reason for believing as some have 
asserted that true polypi never originate in that cavity. Many 
eminent surgeons have testified to having met with true antral 
polypi. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 307 

When a polypus of the benign kind occurs in the antrum, it 
may escape detection until it has completely filled the cavity 
and begun to push its way into the nose and distend the walls 
of the sinus. 

A tumor of the malignant kind might be suspected from the 
pain seated in it, and when enlarged sufficiently to press upon 
the bones, the twofold suffering produced by pressing and being 
pressed must cause greatly aggravated distress. The mechani- 
cal consequences of the continued pressure soon show them- 
selves. The cheek swells, or rather is pushed out, the palate 
and alveolar ridge are depressed ; the molar teeth are loosened, 
the gums become inflamed and spongy, the floor of the orbit is 
elevated ; fistulous openings are often found through which 
sanious pus percolates, or the matter finds its way through the 
opening into the nose, and at length the tumor, pushing through 
the floor of the antrum, appears in the mouth, or forcing its 
way through one or both of the distended nasal openings is 
seen in one or both of the nostrils. 

Of course, the parts subjected to this pressure and disrup- 
tion, become diseased, and inflammation, suppuration, ulcera- 
tion, caries and necrosis, may all be added to the list of secon- 
dary diseases incident to polypus. The causes of polypus are 
not satisfactorily ascertained. Probably they require some con- 
stitutional predisposition to render the parts where they appear 
capable of producing them, and when the susceptibility exists, 
any irritation may be the exciting cause of the morbid growth. 
It is certain that diseased teeth and fangs must be regarded 
as the most common of the existing causes of polypus in the 
antrum. 

The following cases from Jourdain are in point: 
"In 1772, I had occasion to visit a shoemaker, living in 
the Faubourg St. Marcel, who had for some years had a kind 
of exostosis of the right superior maxillary. The tumor was 
as large as a medium sized apple, displaced the nose, deranged 
the palate, and threw the eye upward against the superciliary 
ridge, permitting the lids to open but slightly. The sinus had 
three fistulous openings: one below the malar process, a second 



308 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

near the bicuspids, and a third near the inner canthus of the 
eye. In none was there any discoloration of the skin, and 
alternately, from the two first, there was discharged an acrid 
reddish humor. Most of the teeth of the affected side were 
lost; those which remained were sound, but much displaced 
by the tumor. The right nostril was obstructed by a polypus 
of a scirrhous hardness. In sounding the sinus through the 
fistulous openings, the instrument came in contact with fleshy 
masses in that cavity, some hard, some soft, giving out, when 
wounded, a bloody discharge, resembling wine lees. The na- 
sal wall of the sinus was destroyed, but the maxillary bone was 
not softened. 

"The disease seems to have had its origin in repeated attacks 
of alveolar abscess, the consequence of bad teeth, which usually 
terminated in fistula. Gradually the bone began to swell, and 
the nostril to become obstructed, till his appearance was such 
as I have described. Had I been suffered to operate, I 
would have removed all the teeth, good and bad, involved 
in the tumor, and then making a crucial incision through the 
cheek, would have exposed the bone, which, from its ex- 
treme thinness in this case, I might hope readily to remove. I 
would then have removed the exposed tumors from the antrum, 
by knife, cautery, or both combined, as occasion might suggest; 
looking carefully to the condition of the bone, and seeking, 
after the operation, to establish a healthy suppuration in the part. 

"Case II. — Polypus in the Right Sinus. — In 1773, a lady, 
whose right cheek had been swollen and singularly hard for 
nearly two years, applied to me. 

"The tumor was the result of successive inflammatory attacks 
of the first bicuspis and three molars of that side, only the fangs 
of which remained, and these were covered by a polypous 
tumor that had distended and softened the outer plate of the 
maxillary bone. 

"I first made an incision down to the alveolar sockets, and 
after the arrest of the hemorrhage, removed the roots, twelve in 
number, each having at their extremity a morbid growth, show- 
ing that here was the chief cause of the disease. Their remo- 



DISEASES OP THE ANTRUM OR MAXILLARY SINUS. 309 

val caused considerable hemorrhage. I examined the wound 
on the next day, and found that the bulk of the tumor lay be- 
tween the plate of the maxillary bone, diminishing upwards, 
and terminating at the orbit. 

"Between the cheek and gums were two fistulous openings, 
which discharged a dark, fetid humor. The diseased state of 
the bones decided me to remove the tumor by two vertical in- 
cisions through them. This space permitted me to introduce 
my finger into the sinus. Its membrane was swollen, and there 
was yet a portion of the tumor attached to the orbital plate. 
This, from its propinquity to the eye, I feared to cauterize 
with the hot iron, and therefore used spirit of vitriol, with a 
small quantity of corrosive sublimate dissolved in it, [nitrate of 
silver would be much better,] being careful to employ dry 
dressings, that the escharotic might not, by spreading, cause 
injury to the surrounding parts. 

"After eighteen days use of the same, a healthy appearance 
of the membrane was induced, suppuration established, and at 
the close of the fourth month, after some slight exfoliation of 
bone, the patient was restored." 

With regard to the treatment of antral polypi, it resolves it- 
self simply into making an opening into the sinus, and removing 
the tumor. 

Unfortunately, many of these morbid growths recur after remo- 
val, and grow with more rapidity than at first, and therefore it 
is necessary to destroy the mucous membrane upon which they 
are seated, so as perfectly to eradicate the disease. For this 
purpose, the old surgeons used the actual cautery freely. Proba- 
bly the free application of lunar caustic would accomplish all 
that could be expected from the heated iron. It is often im- 
possible to apply either so completely as to remove every par- 
ticle of the diseased product ; and if the tumor be a result of 
constitutional pravity, we, for the most part, gain little by the 
operation. 

Dr. C. A. Harris thinks that in cases of malignant tumors 
seated in the antrum, the application of the white hot iron is 
indispensable to safety. 
30 



310 DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 

In remarking upon the bold practice of the French surgeons 
in the treatment of these affections, Mr. Thomas Bell commends 
their mode of procedure as worthy of praise and imitation, and 
expresses himself very severely against the timidity of English 
surgeons, who have shrunk from the use of the actual cautery, 
and have left the patient to die with a lingering and painful 
disease, without any attempt at relief. 

Certainly, as life is rendered intolerable, and death inevita- 
ble, by these tumors, we are justified in using any means which 
may promise relief. I have already, (chapter nineteen,) de- 
scribed a malignant fungous tumor which occasionally makes 
its appearance in the antrum. When the disease. is of the ma- 
lignant character, a cure cannot be expected. 

The mode of amputating the superior maxillary, as described 
by Mr. Liston, has also been given in the nineteenth chapter. 

bisects in the Cavity. 

The human body has many parasites inhabiting its various 
tissues. More than a score of these have been described. 
Some infest the intestinal canal, others are found in the heart 
and large arteries; some dwell in the muscular, others in the 
cellular tissue ; some prefer the liver, others the kidneys, and 
some the sinuses of the head. 

The mode by which these creatures are produced, has long 
been a subject of curious inquiry, but it is not necessary for me 
to discuss the subject. It is enough to know that they exist 
within the body, and often prove troublesome inmates. That 
the larvae of insects do find their way into the maxillary sinus, 
is proved by abundant evidence. 

In the Memoirs of the Academy of Surgery, vol. v, p. 233, 
as quoted by Deschamps, it is recorded, that in the course of a 
disease of the maxillary sinus, there issued, from day to day, a 
considerable number of whitish worms, two or three lines long, 
some of which were living. The same author relates two in- 
stances in which long round worms were found in the maxil- 
lary sinus. 



DISEASES OF THE ANTRUM OR MAXILLARY SINUS. 311 

The most singular case of the kind is reported by Mr. Hey- 
sham, a medical practitioner of Carlisle, and may be found in 
Cooper's Surgical Dictionary. 

In this case, the patient was a strongwoman of sixty, who was 
for many years subject to acute pain in the antrum, extending 
over one side of the head. 

These pains never entirely ceased, but were more severe in 
winter than in summer, and were always subject to frequent 
periodical exacerbations. 

The patient had tried anodynes without advantage, and had 
submitted to a mercurial course, by which her sufferings were 
aggravated. All her teeth on the affected side had been drawn. 
At length it was determined to open the antrum, though there 
was nothing to indicate abscess or any other disease in this 
cavity. 

In four days no benefit had resulted from the operation. Bark 
injections and the elixir of aloes were thrown into the sinus. 
On the fifth day a dead insect was extracted by means of for- 
ceps. It was more than an inch long, and thicker than a com- 
mon quill. The patient now experienced relief for several 
hours ; but the pains afterwards returned with the former se- 
verity. Oil was then injected, and two other insects similar to 
the former were extracted. No others appeared, and the wound 
closed. She was much relieved for several months, when the 
pains returned worse than ever, and were particularly com- 
plained of in the frontal sinus. 

We are not informed of further treatment. 

Should worms be found in the cavity, they must be destroyed 
by the injection of oil or other liquids likely to effect the 
purpose. 



CHAPTER XXI. 



DISEASES OF THE PALATE 



The palate is often incomplete through congenital defect. 
It is frequently the seat of disease, which destroys its soft parts, 
and even its bones. 

As the palate forms the vault or roof of the mouth, separating 
it from the nasal cavities, and furnishing a most important part 
of the organ of voice and mastication, its diseases and defi- 
ciencies are of great consequence, exceedingly impairing the 
comfort and usefulness of the subject of them. 

Congenital defects of the palate may differ very much in ex- 
tent. Generally the deficiency is found along the median line, 
sometimes involving only the soft, sometimes also the bony 
structures. At times the fissure extends from the lips entirely 
along the median line of the roof of the mouth, presenting the 
appearance of the two lateral halves of the body not being 
united at this point. 

Congenital defects, however, are not always so regular. 
Errors of formation may occasion an increase of the con- 
cavity of the arch, forcing the alveolar ridges too far apart, and 
producing deformity in the dental range. Sometimes, from an 
opposite condition of things, the alveolar borders maybe brought 
more than usually close together. The teeth may be imper- 
fectly developed, and their texture less dense than usual. 

Mr. Stearns makes three classes of congenital fissure of the 
palate. The first class embraces all the cases in which the fis- 
sure extends through the velum, palate and maxillary bones, to 
the alveolar border, and sometimes through the whole extent of 
the median symphysis. This is usually complicated with 
hare-lip. 

In the second class, the bones of the palate are apparently 
30* 



314 DISEASES OF THE PALATE. 

entire, though the cavity of the arch may be somewhat greater 
than usual, and the fissure extend a short distance into their 
posterior margins. In this case, the lesion is almost wholly 
confined to the velum palati. 

The third class embraces those cases in which the fissure is 
confined to the soft parts, extending, perhaps, only a short way 
up into the uvula. This form of fissure is, probably, less fre- 
quently met with than either of the preceding.* 

When the palate is defective, the voice is impaired, and the 
impairment is in proportion to the extent of the lesion. Some- 
times it is almost entirely destroyed by the inability of the pa- 
tient to utter distinct sounds. Nothing can be more distressing 
than this calamitous injury to the organs of speech, which com- 
bines the distress arising from the consciousness of ludicrous 
appearance with the inconvenience of difficult and imperfect ar- 
ticulation. 

Interference with the voice is not the only evil attending de- 
fects of the palate. Mastication and deglutition are also 
impeded. Food, notwithstanding the patient's careful or in- 
stinctive efforts, will find its way into the nose, causing great 
unpleasantness, and depriving the unfortunate subject of the 
deformity of much of the pleasure of eating, which, after all 
that has been said and written in its disparagement, is unques- 
tionably the most universally prized of all sensual gratifications. 

When the deficiency is congenital, the young infant finds 
difficulty in nursing, but generally, with that preservative in- 
stinct which is given to the little helpless creatures, in such 
perfection as to supply abundantly all lack of experience in 
such matters, the child generally contrives to manage its de- 
fective organs so well as to obviate much of the inconvenience 
naturally attending the deformity. Instead of taking the nipple 
between the upper surface of the tongue and superior gum, &c, 
the infant places the tongue on the nipple, and presses it against 
the lower gum, closing the palatine fissure with the tongue, as 
with an obturator.f 

* Harris' Dictionary of Dental Science, 
f Delabarre. 



DISEASES OF THE PALATE. 315 

The mechanism of nursing is perfected as the child advances 
in life ; dexterity of course increasing with the constant use of 
the parts, until such a proficiency is acquired that solids are 
masticated, and speech is as far as possible performed. The 
mechanism of mastication as performed in such cases is then 
described by Delabarre. When the food is chewed, the ali- 
ment is conveyed between the tongue and movable floor which 
serves for a point d'appui to it, and then it is brought back be- 
tween the teeth. Thus it is that the complicated operation of 
mastication and deglutition is performed without the alimentary 
morsel getting into the nose, or if this does sometimes happen, 
it is the result of accident. 

When perforations of the palatine arch occur in mature life 
through the agency of disease, the patient is in a much more 
unfortunate case than the subject of congenital deformity. The 
latter gradually habituated to the performance of mastication 
and deglutition with his imperfect organs, accomplishes these 
functions, if not well, yet with comparative comfort, while the 
former having been habituated to use the tongue differently, is 
not capable of adopting the mode of procedure applicable to 
his new condition, and consequently is continually passing 
his food and drink into the nose. If the teeth be not properly 
coapted, another source of difficulty and vexation is added, 
as the introduction of the food is thus rendered very trouble- 
some. 

If the velum and uvula be defective or wanting, deglutition 
is exceedingly difficult as the alimentary matters, instead of 
passing comfortably along the pharynx, are, to a greater or less 
degree, forced into the posterior nares. This is the case whether 
the lesion be congenital or accidental. Sometimes deglutition 
can only be effected by throwing back the head as far as possi- 
ble and casting the food into the pharynx. 

The inconvenience of imperfect speech is as serious as that 
of incomplete or difficult mastication and deglutition. 

Mr. Stearns says, that perforation or fissure of the palate may 
render the articulation of some of the letters impossible, and at 
the same time vitiate the character of all the others. The indis- 



316 DISEASES OF THE PALATE. 

tinctness of utterance is usually proportioned to the extent of 
the lesion. Thus, when the fissure extends as far as the alveo- 
lar processes, the patient loses several of the letters, which an- 
other, with only a portion of the soft palate involved, is able to 
produce with considerable distinctness. In cases of fissure, 
particularly those of the more extensive kind, the movements of 
the tongue are comparatively limited, as the patient is instinc- 
tively aware that the very effort he should make in order to 
give letters their appropriate articulation, often serves to ren- 
der the impediment more painful. So far, indeed, is this inac- 
tivity of the organs sometimes persisted in, that speech becomes 
little else than the emission of a succession of vowel sounds, 
which, in lieu of receiving proper consonant adjuncts, are only 
made intelligible by the accompanying inflection, key, gesticula- 
tion and expression of countenance, all of which are, more or 
less, the vehicles of thought.* With the limited action of the 
tongue, nearly all the muscles concerned in the formation of ar- 
ticulate sounds, in a greater or less degree, participate, while the 
muscles about the nose, as the compressor nasi and depressor 
nasi are violently contracted for the purpose of closing the nos- 
trils and preventing the escape of the sound. This gives a par- 
ticularly disagreeable aspect to the features. 

The most common cause of lesions of the palate is syphilis. 
This terrible disorder, when once it becomes constitutional, pro- 
duces a number of strange local affections, differing very much 
from one another, all of them distressing, and some of them 
dangerous, and not unfrequently fatal. 

Beginning as a local affection, usually a primary sore, 
syphilis may gradually poison the whole circulating fluids 
and cause defects of nutrition and alterations of tissue in various 
parts of the body. 

The manner of effect produced by secondary syphilis, differs 
very much in different persons, as it is influenced by a variety 
of determining or modeling circumstances. Eruptions upon 

* Observations on Congenital Tissue of the Palate, with some remarks 
on Articulation and Impediments of Speech, by Charles W. Stearns, Esq., 
Surgeon, London. 



DISEASES OF THE PALATE. 317 

the surface, local inflammations, ulcers, augmentation and loss 
of parts, may all be occasioned by the penetrating and potent 
virus. 

The soft parts about the throat are particularly apt to be the 
seat of constitutional syphilitic ulcers, and the bones of the 
palate are very frequently perforated or wasted by venereal 
caries. 

It is very necessary, however, to be aware that palatine ul- 
ceration, caries and necrosis may occur from other than a vene- 
real cause. It would be terrible indeed to add the cruel suspi- 
cion of such a malady to the sufferings of a patient whose dis- 
ease, having no affinity to lues, should claim sympathy instead 
of begetting contempt and disgust. We must, therefore, be 
very careful to make no mistakes in matters of such delicacy. 
Moreover, the treatment of these affections must depend upon 
the accuracy of the diagnosis, and that which would be judi- 
cious in the case of syphilitic affection might be very improper 
under other circumstances. 

When the true history of the case can be obtained, the facts 
will give much assistance in forming an opinion, but this can- 
not always be procured ; we are, therefore, commonly obliged 
to form our opinion from the appearances before us. 

The only constitutional vice, other than the venereal, which 
may cause a similar palatine devastation, is scrofula, and when 
scrofula is the cause of the affection, the prevalent vice will 
display itself elsewhere, in derangements of the lymphatic sys- 
tem, and the other affections which usually attend upon this 
general pravity. 

Syphilis is more rapid than scrofula ; and the local affec- 
tions produced by it are more painful. According to Mr. Hun- 
ter, venereal disease generally makes its appearance, in these 
parts, at once, in the form of an ulcer without much previous tu- 
mefaction. He describes the ulcer as a fair loss of substance, part 
being dug out as it were from the body of the tonsil (if seated 
upon it.) It has a determinate edge, and is commonly very 
foul, having a thick white matter like a slough, adhering to it, 
and not admitting of being washed away. All authors, how- 



318 



DISEASES OF THE PALATE. 



ever, admit the extreme difficulty of distinguishing venereal 
affections in these parts, with absolute certainty, by merely 
local observation, and no appearance of sores about the palate, 
warrant us in declaring the disease syphilitic, without corres- 
ponding symptoms justify the suspicion. While this is the 
case, however, any suspicious sore will authorize us to try 
such remedies as are known to be efficacious in syphilis, it 
being much more dangerous to neglect a syphilitic sore than 
temporarily to maltreat a scrofulous one. No purity on the 
part of a married female can always be satisfactory of her free- 
dom from syphilitic taint, as, disgraceful as it is to human nature 
to make the confession, we are frequently compelled to recog- 
nize the ravages of the disease in these victims to the matrimo- 
nial tie, who are perfectly innocent of any impropriety. I need 
not say, that when the dentist discovers such a conditon to ex- 
ist, though humanity will demand that in some way or other 
the cure be provided, benevolence, no less imperious, requires, 
that the unfortunate subject of the odious inocculation shall be 
kept in blissful ignorance of the nature of the malady. 

Of course, where venereal or scrofulous disease is at work 
upon the parts, proper constitutional remedies must precede all 
mere mechanical attempts to repair existing damage. 

The devastation of the palatine tissues, soft or bony, may 
sometimes result from the local irritation produced by dead 
teeth, &c. This, of course, can only occur in those enfeebled 
constitutions in which nature is not able to resist even a trivial 
morbid impression, but seems barely capable of maintaining a 
nutrition equal to the ordinary wear and tear of tissues. 

That such cases do occur, is stated by Jourdain, Harris 
and many others. 

Harris says,* "The local irritants occasioning the palatine 
diseases are dead and loose teeth, roots of teeth, salivary calcu- 
lus, mechanical injuries, acrid humors, &c. The case of a 
lady of irreproachable character is related by Jourdain, in whom 
a scratch on the palate with a fish bone, caused a tumor, which 

* Dictionary of Dental Science, art. Palate. 



DISEASES OP THE PALATE. 319 

suppurated and degenerated into an ulcer with hard elevated 
edges and a fungus in the middle." Dr. Cone mentions a simi- 
lar case. 

The following are reported by Jourdain : 

Case I. — Mr. Noel had a tumor of the palate, which, on 
pressure, discharged pus through one fistulous opening on the 
outer side of the right alveolus, between the canine and incisor, 
removed some time since. The patient would not consent to 
and another in the socket of the second molar, which had been 
proper measures in the first instance. The canine incisors and 
first molar became loose and were extracted : the alveolus 
around the site of the second molar sloughed away. The tu- 
mor still continued to enlarge, and some embarrassment was felt 
in the nostril : the patient then put himself under my care. The 
tumor, when lanced, discharged a very fetid pus, and I found, 
on introducing my probe, that a portion of the palate and max- 
illary bones were necrosed and almost completely detached. I 
removed them with ease : the one from the palate was the size 
of the nail of the index finger, that from the maxilla, larger. 
The removal of these sequestra, exposed the pituitary membrane 
of the floor of the nostril, as was proved by the sneezing ex- 
cited by touching it on the lingual side. I dressed the wound 
for some days with dry lint, and then used gargles, &c. In 
twelve days the cicatrix was complete. 

I have treated many similar cases, arising from simple ab- 
scess, the sequel of dental disease. I have always, when the 
opening was of sufficient size either awaited the natural separa- 
tion of the sequestrum, or when assured that it was no longer 
adherent to the second bone, gently withdrawn it. Simple 
causes may often be productive of extensive injury, as the fol- 
lowing case will show : 

Case II. — A bailiff, named Broch had a tumor of the palate 
is large ae a pigeon's egg, with swelling of the nose and upper 
lip, consequent of a decayed condition of the teeth. Pus 
escaped from the nose and there was a fistulous canal from the 
second incisor to the first molar of the left side. 

As the case seemed an urgent one, I removed the decayed 



320 DISEASES OF THE PALATE. 

teeth and stumps, thus destroying the fistula. I then excised the 
the palatine tumors, found the bone carious and the nasal mem- 
brane covering it perforated, which accounted for the discharge 
of pus from the nostril. I first employed dressings of dry lint, 
emollient and detergent gargles, and after the subsidence of lo- 
cal inflammation, touched the bone with mercurial water twice 
in eight days. In this time the sequestrum separated, leaving 
an opening into the nostril about the size of a quill, which was 
closed by a prolongation of the mucous membrane. I made 
use of dressings of dry lint, gently applied, and occasional 
styptics to suppress exuberant granulations. The entire cure 
occupied six weeks. 

For a great number of similar cases, the reader may consult 
Jourdain's work. 

When local irritants cause or seem to be connected with the 
disease, they should be promptly and completely removed. 
The after treatment will be conducted upon general surgical 
principles. 

When a fissure has been permanently formed and its limits 
ultimately defined, whether it has been congenital or accidental, 
the indication is to remove the deformity by producing a closure 
of the fissure, or, if this cannot be done, to supply the defi- 
ciency of the parts by such mechanical appliances as may be 
deemed most suitable. 

When the soft palate or some portion of it has been lost, the 
lesion has been substituted by means of an operation, which has 
been termed staphyloplasty* 

The operation can be successful only when the perforation is 
small. It consists in detaching a portion of mucous membrane 
from the surrounding parts, and so adjusting them with refer- 
ence to the perforation, as to procure a permanent covering of 
the cavity, when adhesive inflammation has been effected. 
The operation is difficult, and requires great dexterity in exe- 
cution as well as ingenuity in contrivance. Dr. Pancoast, in 
his Operative Surgery, describes an operation of this kind, 

*2ta$v%rj, the uvula, and mkaSSco, I form. 



DISEASES OF THE PALATE. 321 

successfully performed by himself, to close a hole near the 
centre of the hard palate, which formed a communication be- 
tween the nose and mouth. 

The operation for closing a cleft palate is called staphylor- 
aphy.* It consists in paring away the edges of the fissure and 
closing them so perfectly as to produce union by adhesion. 

The operation has been successfully performed by a great 
number of surgeons, European and American, and several 
methods of performing it have been adopted and suggested ; 
each having its advocates. 

Dr. S. P. Hullihen, surgeon dentist of Wheeling, Va., of whose 
surgical skill I have already made mention, had performed this 
operation successfully eleven times, up to the year 1849. This 
ingenious surgeon has invented a bistoury for paring the edges 
of the fissure, which possesses decided advantages over the 
ordinary double edge knife. It is composed of two parts, 
which open like scissors, but when closed, form a double edged 
knife or bistoury. The manner of using it is as follows : after 
first seizing the cleft edge of the velum, at the base of the 
uvula, with a pair of curved forceps, and putting it on the stretch, 
the bistoury with its back towards and against the palate bone, 
should be pushed through the velum near its edge ; then, by 
opening it, the edges will be pared off in the most even and 
perfect manner possible. 

Further procedure should be suspended until the hemorrhage, 
although seldom very great, shall have partially subsided. A 
needle, armed with a well waxed ligature, and held in a pair of 
suitable forceps, should be passed from before backwards, 
through the most dependent part of the left margin, about three 
lines from the edge. As soon as it is seen on the opposite side, 
it should be grasped by the assistant, with a pair of long handled 
forceps, and as soon as the hold of the port-aiguille is relaxed, 
drawn through, replaced in the latter, and passed through from 
behind forwards, the right margin of the velum opposite to the 

* tt atyvht], and Pa^, a suture. 

31 



322 DISEASES OF THE PALATE. 

left. After the patient has rested a few minutes, a second, 
third, or fourth ligature should be introduced.* 

Dr. J. C. Warren and his son, Dr. John Mason Warren, 
have each performed this operation repeatedly, and with great 
success. In most of these cases the fissure has extended through 
both soft and hard palate, and in one case through the jaw 
and lip. 

Dr. J. M. Warren's method has been to dissect off the mu- 
cous membrane from the hard palate, on either side, and stretch 
this across the fissure and then unite the edges by sutures. 

Although it is generally asserted by surgical writers, that 
when the fissure of the hard palate exceeds an inch, no union 
can be expected, Dr. Warren has proved by his success in 
such cases, that the opinion is erroneous. f 

Dieffenbach recommends that a longitudinal incision be made 
at a short distance from the edges of the fissure, in order to 
permit the closure to be accomplished in the way before men- 
tioned. 

A great variety of instruments has been invented by different 
surgeons, and recommended to be used in this operation. I 
have already mentioned the cutting scissors of Dr. Hullihen. A 
variety of needles and needle-holders has been proposed. Dr. 
J. C. Warren uses a needle with a movable point. Dr. N. R. 
Smith prefers a simple lance-shaped instrument, mounted on 
a handle, and having a slit near its point, which opens at its 
posterior end. The needle is broader in front of the eye than 
behind it, which renders the passage of the back part easier. 
Armed with a ligature, the curved portion of the needle is car- 
ried beyond the fissure, and its point introduced behind the 
middle of the uvula, and as soon as it has come out far enough 
to expose the ligature in the slit, the ligature is taken hold of 
with a tenaculum, disengaged from the slit or eye in the needle, 
and the needle is withdrawn. A second ligature is introduced, 
half an inch higher up, and, if necessary, a third, at an equal 

* Die. Dental Science. 

f Reese's Cooper's Surgical Dictionary. 



DISEASES OP THE PALATE. 323 

distance from the second. With the ends of the ligature passed 
through the uvula, this part is drawn forwards, until the fissure 
in the soft palate shall assume a nearly horizontal position. Its 
edges are then cut off with scissors or bistoury. The ligatures 
are then tied, and the ends cut off. 

Dr. Hullihen has invented an instrument for passing the 
needle, which he calls an acutenaculum, and which he thinks 
better adapted to the purpose than any other. It is composed 
of a staff and a slide. The staff is a small steel bar, six inches 
in length, a fourth of an inch in breadth, and an eighth of an 
inch thick, with an arm at the upper end, rising at a curve from 
the staff, and half an inch long. On the external or superior 
side of this arm a duplicate arm is retained by a steel spring 
attachment, which brings the two arms in close contact, form- 
ing the jaws of the instrument. Between these two arms, and 
on the duplicature, is a small groove, formed to receive the 
ligature; and when the ligature is pressed between the jaws of 
the instrument, they open, and it slides to the point designated 
for its reception, and immediately below which, the jaws are 
perforated with a hole for the introduction of the needle. 

Two inches from the inferior end of the staff, a pair of rings 
are affixed, to receive the thumb and index finger, the rings 
standing parallel with the staff, and sideways to the direction 
of the arms of the instrument. A slide formed of steel, equal 
in length, thickness and breadth to the staff, is made to fit the 
upper surface of the staff, and to move with ease up and down 
upon guides placed on the same. From the superior end of 
the slide is a short straight spear-shaped needle, constructed 
with an eye just back of its point, with a small notch opening 
to it from the upper surface. 

When the ligature has been fitted in its place in the jaws of 
the instrument, and the slide adjusted to the staff, the slide is 
forced upwards, the needle and jaws approach each other, and 
the needle passes through the hole in the latter, just under the 
ligature, which is caught in the notch of the needle, and as the 
slide is drawn backwards the eye of the needle is threaded, and 
the ligature drawn through the velum. This instrument is cer- 



324 DISEASES OF THE PALATE. 

tainly an ingenious one, and the preference given it by the in- 
ventor, who has operated so often and so well, is sufficient com- 
mendation. 

For a more particular description of this instrument, made 
intelligible by an accompanying plate, the reader is referred to 
an excellent article on cleft palate, by Dr. Hullihen, published 
in vol. v, page 166, of the American Journal of Dental Sci- 
ence. Concise and admirable directions will also be found in 
that paper, for conducting every step of the operation. 

When the loss of parts is so great as to forbid an attempt to 
close the fissure by an operation, nothing remains to be done 
but to cover it by a gold plate or obturator, such as the cir- 
cumstances of the case will admit. The skilful dentist will 
often be able to remedy these serious lesions to a very great 
extent, by well devised and artistically executed substitutes. 

For a description of these mechanical means, and the mode of 
adjusting them, I refer the reader to the works on mechanical 
dentistry. 






_^ 



